64). Again, this has been recently evidenced by the recent battles in Congress over the federal budget. Although the budget deficit did not directly involve health care policy, the result was a compromise on the budget that required a corresponding change in the health care policy as to Medicare. This is not an unusual situation in the area of health care policy. Often, budgetary concerns must be addressed which in long-term have an impact on the formation of health care policy. The formation of health care policy does not occur in a vacuum and there is a constant struggle between interests. Too often the concerns of the majority are afforded too much consideration and the interests of smaller and seemingly less important segments of society are overlooked. This is a serious problem for policy makers and one that reoccurs frequently but a problem that is inherent to the process that policy is developed in a democratic society (p.68).

4) Discuss the concept of incrementalism in public policymaking.

One of the phenomena of policy making is the concept of incrementalism. In some isolated situations, public policies might undergo wholesale changes but in most cases public policy changes in stages which is described as incrementalism (p.150). The enactment of the Medicare program and the recent enactment of the Affordable Care Act are both examples of wholesale change but such enactments are the exception. The general governmental approach to policy change is to do so by building upon existing programs and modify them in response to what are seen as current needs. Wholesale changes are viewed as being disruptive and tending to upset the equilibrium that governments tend to prefer.

The process of incrementalism is believed to more predictable and the result is greater stability. It is only in the direst of circumstances that wholesale changes are considered; when an immediate or radical change is viewed as necessary....

Because most policy changes demand that compromise be made between the parties, incrementalism makes such compromise more palatable for those concerned. Because the proposed changes are minimal, there is less chance for there to be major disagreement on the issues (p.150). In situations demanding wholesale change, there is less room for compromise as the parties are not confident how such changes will impact society. When the changes are minimal, the parties are more prone to experiment with new ideas because there is less to lose if the new ideas are not successful. With wholesale change there is a greater chance that the program will fail and picking up the pieces of such failure will be more difficult and expensive (p.151).
5) Discuss the cyclical relationship between rulemaking and operation and how this affects policy modification.

Rule making is an essential part of the policy making process (p.154). On very rare occasions is the legislation that sets forth a specific public policy detailed enough to set forth how the public policy will be implemented. The agencies responsible for executing the public policy set forth in new legislation are entrusted with the responsibility of determining how such policy will be administered. Not unexpectedly, the rule making process not only implements the purposes for which the legislation was enacted it also results in additional rules being formulated that go beyond the intent of the original legislation and expands the power and influence of the legislation.

Over the course of time the individuals responsible for rule making will also participate in modifying the rules. As the public policy legislation begins to be operational certain aspects of the legislation may prove to be impossible to implement or require some minor adjustments in order to allow the public policy to be effective. The pressures for such modification can be generated from within the agency administered the policy or externally from the individuals and organization directly affected by the policy (p.154).

The intermingling of the relationship between those experiencing the consequences of policies, those implementing the policies, and those designing the policies is often described as an "iron triangle (p.156)." This triad of interests often becomes impenetrable and immune from attack or influence from outside sources. A symbiotic relationship is created that affords the policy, its administrative agency, and the recipients of its policy a life all its own.

Health Care Politics and Policy