Breaking gridlock: the determinants of health policy change in Congress

Prior to the 2010 health care reforms, scholars often commented that health policy making in Congress was mired in political gridlock, that reforms were far more likely to fail than to succeed, and that the path forward was unclear. In light of recent events, new narratives are being advanced. In formulating these assessments, scholars of health politics tend to analyze individual major reform proposals to determine why they succeeded or failed and what lessons could be drawn for the future. Taking a different approach, we examine all health policies proposed in the U.S. House of Representatives between 1973 and 2002. We analyze these bills' fates and the effectiveness of their sponsors in guiding these proposals through Congress. Setting these proposed policies against a baseline of policy advancements in other areas, we demonstrate that health policy making has indeed been far more gridlocked than policy making in most other areas. We then isolate some of the causes of this gridlock, as well as some of the conditions that have helped to bring about health policy change.     

Obligation and welfare policy

Ronald Reagan came to the White House with a reputation for welfare reform that dated from his days as governor of California. The administration's first step was to restrict benefits to working recipients in ways similar to procedures originally proposed in that state. The impact on the AFDC caseload of these changes, however, was modest, and, ironically, the work program opportunities provided by legislation sponsored by the Reagan administration have been exploited as successfully by Democrats such as Michael Dukakis of Massachusetts as by Republicans. Despite frequent references to welfare and welfare problems since 1981, the administration has been notably short of ideas.The silence from the White House has been filled by outsiders - first Murray and then Mead and others such as journalists Mickey Kaus (1986) and Nicholas Lemann (1986). While Losing Ground argued for the government's retirement from the field in the War on Poverty, Mead offered a vision certain to make both liberals and the administration uncomfortable. On the one hand, his demand for creative statecraft calls for substantial government activism, a renewed attack. On the other, his assertion that further progress will require attention to behavioral issues challenges the liberal attitude that what the poor need most is the empowerment that cash can provide. For the concerned public, something about Mead's argument rings true. The poverty we see - homeless derelicts, children of mothers who are children themselves, recipients who reach midlife never having known anything but welfare dependency, neighborhoods in which everyone receives support - hardly seems vulnerable to negative tax payments. And, as Mead suggests, eliminating the present system would create unacceptable hardship. Even if financial incentives are the prime movers in most areas of economic life, we are all a bit embarrassed by them; in the abstract it seems better to say that absent parents are obligated to support their children and able-bodied adults are obligated to work.     

The TANF/SSI connection

Interactions and overlap of social assistance programs across clients interest policymakers because such interactions affect both the clients' well-being and the programs' efficiency. This article investigates the connections between Supplemental Security Income (SSI) and Temporary Assistance for Needy Families (TANF) and TANF's predecessor, the Aid to Families with Dependent Children (AFDC) program. Connections between receipt of TANF and SSI are widely discussed in both disability policy and poverty research literatures because many families receiving TANF report disabilities. For both states and the individuals involved, it is generally financially advantageous for adults and children with disabilities to transfer from TANF to SSI. States gain because the federal government pays for the SSI benefit, and states can then use the TANF savings for other purposes. The families gain because the SSI benefits they acquire are greater than the TANF benefits they lose. The payoff to states from transferring welfare recipients to SSI was substantially increased when Congress replaced AFDC with TANF in 1996. States retained less than half of any savings achieved through such transfers under AFDC, but they retain all of the savings under TANF. Also, the work participation requirements under TANF have obligated states to address the work support needs of adults with disabilities who remain in TANF, and states can avoid these costs if adults have disabilities that satisfy SSI eligibility requirements. The incentive for TANF recipients to apply for SSI has increased over time as inflation has caused real TANF benefits to fall relative to payments received by SSI recipients. Trends in the financial incentives for transfer to SSI have not been studied in detail, and reliable general data on the extent of the interaction between TANF and SSI are scarce. In addition, some estimates of the prevalence of TANF receipt among SSI awardees are flawed because they fail to include adults receiving benefits in TANF-related Separate State Programs (SSPs). SSPs are assistance programs that are administered by TANF agencies but are paid for wholly from state funds. When the programs are conducted in a manner consistent with federal regulations, the money states spend on SSPs counts toward federal maintenance-of-effort (MOE) requirements, under which states must sustain a certain level of contribution to the costs of TANF and approved related activities. SSPs are used for a variety of purposes, including support of families who are in the process of applying for SSI. Until very recently, families receiving cash benefits through SSPs were not subject to TANF's work participation requirements. This article contributes to analysis of the interaction between TANF and SSI by evaluating the financial consequences of TANF-to-SSI transfer and developing new estimates of both the prevalence of receipt of SSI benefits among families receiving cash assistance from TANF and the proportion of new SSI awards that go to adults and children residing in families receiving TANF or TANF-related benefits in SSPs. Using data from the Urban Institute's Welfare Rules Database, we find that by 2003 an SSI award for a child in a three-person family dependent on TANF increased family income by 103.5 percent on average across states; an award to the adult in such a family increased income by 115.4 percent. The gain from both child and adult transfers increased by about 6 percent between 1996 (the eve of the welfare reform that produced TANF) and 2003. Using data from the Department of Health and Human Services' TANF/SSP Recipient Family Characteristics Survey, we estimate that 16 percent of families receiving TANF/SSP support in federal fiscal year 2003 included an adult or child SSI recipient. This proportion has increased slightly since fiscal year 2000. The Social Security Administration's current procedures for tabulating characteristics of new SSI awardees do not recognize SSP receipt as TANF We use differences in reported TANF-to-SSI flows between states with and without Separate State Programs to estimate the understatement of the prevalence of TANF-related SSI awards in states with SSPs. The results indicate that the absolute number of awards to AFDC (and subsequently) TANF/SSP recipients has declined by 42 percent for children and 25 percent for adults since the early 1990s. This result is a product of the decline in welfare caseloads. However, the monthly incidence of such awards has gone up-from less than 1 per 1,000 child recipients in calendar years 1991-1993 to 1.3 per 1,000 in 2001-2003 and, for adult recipients, from 1.6 per 1,000 in 1991-1993 to 4 per 1,000 in 2001-2003. From these results we conclude that a significant proportion of each year's SSI awards to disabled nonelderly people go to TANF/SSP recipients, and many families that receive TANF/SSP support include adults, children, or both who receive SSI. Given the Social Security Administration's efforts to improve eligibility assessment for applicants, to ensure timely access to SSI benefits for those who qualify, and to improve prospects for eventual employment of the disabled, there is definitely a basis for working with TANF authorities both nationally and locally on service coordination and on smoothing the process of SSI eligibility assessment. The Deficit Reduction Act of 2005 reauthorized TANF through fiscal year 2010, but with some rules changes that are important in light of the analysis presented in this article. The new law substantially increases effective federal requirements for work participation by adult TANF recipients and mandates that adults in Separate State Programs be included in participation requirements beginning in fiscal year 2007. Thus SSPs will no longer provide a means for exempting from work requirements families that are in the process of applying for SSI, and the increased emphasis on work participation could result in more SSI applications from adult TANF recipients.     

When Are Women More Effective Lawmakers Than Men?

Previous scholarship has demonstrated that female lawmakers differ from their male counterparts by engaging more fully in consensus‐building activities. We argue that this behavioral difference does not serve women equally well in all institutional settings. Contentious and partisan activities of male lawmakers may help them outperform women when in a polarized majority party. However, in the minority party, while men may choose to obstruct and delay, women continue to strive to build coalitions and bring about new policies. We find strong evidence that minority party women in the U.S. House of Representatives are better able to keep their sponsored bills alive through later stages of the legislative process than are minority party men, across the 93^rd–110^th Congresses (1973–2008). The opposite is true for majority party women, however, who counterbalance this lack of later success by introducing more legislation. Moreover, while the legislative style of minority party women has served them well consistently across the past four decades, majority party women have become less effective as Congress has become more polarized.