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Journal of Health Politics, Policy and Law 28.2-3 (2003) 509-515



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Unchanging New Leadership

David M. Frankford
Rutgers University


Each of these fine articles discusses the possibility that the twenty-first century might witness new leadership in health care. 1 Any such discussion of new leadership, necessarily, carries within it an implicit concept of change. Leadership is new because it moves the world in a direction that is different than the previous path taken. I want to tease out the possibilities of change raised by these essays. The bottom line is that change, to be significant, would have to be multifactorial or multisectorial such that I am even more pessimistic than most of the authors seem to be.

Out of an abundance of caution, I should say that I do not offer a theory of change, or even a typology of change. More modestly, I just build upon the very scientific observations that change involves more than rearranging the deck chairs on the Titanic and that there are framing issues in deciding when change occurs. Definitions of change have longitudinal or temporal aspects, as well as latitudinal ones, involving issues concerning breadth of change. Each of these involves different degrees of abstraction. For example, most people would characterize the passage of U.S. Medicare as rather significant change because the legislation was, as Ted Marmor (2000) describes, a rare legislative moment for the U.S. Congress. However, at a different level, the change was not so vast because the legislation left intact the extant understanding of how health care was to be delivered, the relationship between a finance system and providers, and the relationship [End Page 509] among different payers, of which the federal government became just one competitor among many. Over time, this lack of change in these dimensions have perhaps made the change wrought by the program less significant, as witnessed by the fact that beneficiaries' out-of-pocket costs are now higher than what they were before passage and there is a serious possibility that Medicare will become a voucher-based program. I do not mean to be deterministic about this, and do not contend that the seeds of a program's destruction are inevitably planted in its creation, but instead wish to analyze the nature of change in our current context.

What I want to do is, first, put all the articles together to highlight what multifactorial or multisectorial change would look like. I will then pull them apart to emphasize that while together change in different domains might stand, divided change in each will probably fall.

And so, to the essays.

In her article, ConnieNathanson discusses the possibility that grassroots advocacy will lead the United States to significant financing reform, including national health insurance. Regarding this possibility, she is pessimistic. Grassroots advocacy groups, she says, thrive because of our fragmented political structure and individualistic political culture, which in turn "blunt their power to effect change" (447). Any advocacy group that seeks change will possibly spark an array of countervailing power. Advocacy groups that have overcome this resistance have tended to be ones that focus on relatively narrow issues like nonsmokers' rights. On the one side, narrow issues allow advocacy groups to rely on preexisting "dense social and political ties" (449) such that the problem of collective action is less difficult. On the other side, more modest issues spark less breadth of opposition. In addition, not every narrow issue will do. Instead, ones that enable advocacy groups to form alliances with established "insider" organizations and individuals are more likely to succeed because of the increased legitimacy and access to established political resources and structure gained. Moreover, not every wrong deserves a right. The situations of so-called "innocent" victims of HIV, for example, those whose infections derived from blood transfusions, play very well, while the stories of those victims who simply claim that they have gotten the small piece of the social pie do not. Thus, if you put it all together, grassroots advocacy may at best enable us to enact such "sweeping" reforms...

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