The making of American domestic policy 239the organisation of Congress further fragmented political power among con-
gressional committees and, by adopting procedures such as the filibuster in
the Senate, gave significant power to individual members of the legislature.
The political party system, instead of coordinating the disparate parts of the
system, is itself decentralised and weak, reinforcing its disintegrative char-
acter. The system of pressure groups sprang up to fill the vacuum in policy-
making that was created. The making of policy, therefore, is not centrally
controlled or coordinated. There is no single pattern to decision-making. The
process depends upon four factors:
- the nature of the issue that is to be decided;
- the particular groups that are interested in the outcome of that issue;
- the bearing of ‘public opinion’ on the issue, and the perception of Senators
and Congressmen of its importance to their prospects for re-election; - the circumstances of the national or international political environment
at the time that the issue comes up for decision.
Thus the processes by which individual policy decisions are made differ
considerably. Each issue is unique; they are decided by changing coalitions
of interest groups, with the involvement of governmental agencies; different
weights are given to the influence of the president or congressional party
leaders; some issues depend almost entirely on decisions of the courts, others
are not susceptible to solution through judicial procedures.
In this chapter we will examine a number of areas of domestic policy-mak-
ing in order to illustrate the various factors that influence outcomes. The
first of these is the attempt to reform the American system of health care, a
subject that dominated the first two years of President Clinton’s first term
of office.
Health care reform
The major source for the provision of health care cover is private insurance.
Insurance companies and Health Maintenance Organisations (HMOs) issue
policies. The premiums are paid by employers to provide benefits for their
employees, by individuals to provide cover for themselves or their families,
or by a combination of these. The HMO or the insurance company pays the
hospital bills, the doctors, and the cost of drugs, accommodation, etc. The
problem with this kind of private provision is that it is very variable in its
coverage. Limits may be set by the insurers to the total amount that can be
claimed over the period of a person’s life span. Policies differ in the extent to
which they cover chronic or catastrophic illness, mental illness or pregnancy,
and the extent to which family dependents are covered, and of course the
insurance system does not provide automatic coverage for the unemployed,
the disabled and the elderly. The system also suffers from administrative
complexity and soaring fees for hospitals and doctors, and is subject to fraud