3.1 Agenda Setting

Profs Jarman and Greer explain how some problems get on the political agenda while others are ignored. How can health policy advocates use Kingdon's 'three streams' model to better understand the political process and their chances of creating change?

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• Music: 'Blippy Trance' by Kevin MacLeod

Transcript

Holly Jarman: 0:10

Hello, and welcome to another HMP Governance Lab Podcast. I'm Holly Jarman. And I'm here with Professor Scott Korea. And we're going to talk today about agenda setting. Which leads me to my first question, which seems like a very obvious one. What is an agenda? Scott,

Scott Greer: 0:29

if you've ever been to a meeting, the agenda is the list of things you're going to discuss. And that gives us the metaphor for the political agenda, although I'll point out that anybody in any political system knows exactly what you're talking about when you ask him, what's the agenda? It's what we're talking about. It's the set of issues that's dominating the airwaves and the thinking of key political figures.

Holly Jarman: 0:49

So in other words, it's not this quite the same. There's not an email with an agenda. There's not a piece of paper with an agenda. It's what's on the minds of people who are engaged in policymaking.

Scott Greer: 1:00

But in a year, like 2020, for example, you knew the agenda was COVID-19. And racism. That was what was being talked about. And and if your issue wasn't related to those, you were probably not on the agenda.

Holly Jarman: 1:13

So how do you get from an agenda to actual policy actions?

Scott Greer: 1:19

That's the thing being on the agenda, having everybody talking about you isn't the same thing as for example, passing legislation. So an idea for example, for years it was cap and trade to address climate change was on the political agenda constantly. But it barely got votes in Congress, let alone actual passage. So you can be on the agenda for a very long period of time. That's not the same thing as having your bill be introduced and marked up and voted through and signed.

Holly Jarman: 1:47

So if I'm a policy advocate, how do I try to get something on the agenda?

Scott Greer: 1:54

Well, first of all, remember that if you and your interest in policy, you're only part of what's going on? Washington is knee deep in people who have ideas about policy. What's the research of John Kingdon, done at the University of Michigan, actually, where he taught here for decades, taught us is that the agenda comes from the confluence the coupling of three streams that normally exist independently, the policy stream policy ideas and their entrepreneurs, politics, what senior political figures are trying to do? And problems, things that catch our attention, like pandemics or wars or crip plane crashes? or what have you.

Holly Jarman: 2:31

Okay, so let me recap. There's three streams in kingdom's theory, what, what is the first one? What is the policy stream all about?

Scott Greer: 2:41

Well, the first one, the policy stream is the one that tends to most naturally interest people in places like schools of public health. It is the people and the ideas that they advocate for. So in the policy stream, you find policy entrepreneurs, who are people with a policy idea that they're trying to sell, and they're like any other kind of entrepreneur, they've got their gadget, and they'll sell it, and they'll try to sell it as a dessert topping. And if that doesn't work, maybe they'll sell it as something that cleans oil off the driveway.

Holly Jarman: 3:09

So what are some examples of that? So we're talking about things like tobacco 21, for example, that we often talk about in this class, or value based insurance design, or justice 40? What are some other examples,

Scott Greer: 3:25

I'm spending a lot of money on healthcare information technology, that's a one that I want to underline because the thing about the policy stream is it's full of ideas, such as the ones Holly just listed. But it's full of ideas, not because the ideas are needed, not because society in some way, sat down and figured out what its problems are and conducted an analysis based on good epidemiology or whatever of what was required, and then set out to find solutions, nothing of the sort. policies exist because they have somebody who's an entrepreneur who is pushing them and advocate who is pushing them. And part of the entrepreneurialism of a policy advocate is figuring out how the policy that they're trying to sell is relevant to whatever the problem and the politics are of the day in order to get it onto the agenda. So I've done presentations to 1000s of people about this framework. And one of the things I always do is I say, put your hand up, if you ever have found any problem whatsoever in public health or health care services that you haven't been told will be solved by massive Information Technology expenditure. And on one blustery day in Scotland in some nameless room, some poor man put up his hand and he said rural health care, and there was a moment of shock. And then the whole rest of the room said telehealth is always put forth as the solution for rural health care. The point I'm making is this people who through some combination of conviction and being paid suggests that the solution to everything is Healthcare Information Technology expenditure. Part of their job is to figure out what those being what other people who influenced the political agenda want, and explain to them how increased health IT expenditure will help. So if you go a long way back to the Obama administration, initially, Obama came into the middle of an enormous economic collapse. And one of the things they wanted was ways to spend federal money quickly to employ people quickly on something. And the case for healthcare information technology was partly that you could scale up the number of programmers producing frankly, often very mediocre software really fast. So the case for expanded EHRs was partly that healthcare will get better. But it was also that it was a way to put a lot of people to work quickly, without doing environmental impact statements or waiting for it to be the season to pour concrete.

Holly Jarman: 5:42

So that sounds like a very important sense of awareness that people need to cultivate if they want to try to influence health policy or create change in health. Is this idea that these policy ideas are a little bit independent from the real things that might be happening in communities around the country? So the second stream? What is the politics stream? That sounds odd to me? Because it sounds like it describes everything we've talked about so far, how is this distinct?

Scott Greer: 6:12

Well, the policy entrepreneurs are people who work in advocacy organizations, they work in academia, they work in think tanks, their lobbyists. Politics is the political decision makers, it's the legislators, it's the president. It's the executive branch, it's their staffers, it's their equivalents at the state and local level. And they basically have one job, which is to remain in office and gain power. And even if you say, Oh, they should be motivated by the good of their citizens or something, well, you're only going to achieve the good of the citizens if you get reelected. So you have to be paying attention to your own political advancement, no matter what your motivations are. So the politics stream is made up of people who are saying, If I catch on to this issue, if I catch on to this policy idea, I can advance my career, get elected, get reelected, build my power base, achieve something by having made this my issue. And their incentives are to do with things like advancement within their political parties, electoral calendars, election timing, and above all, the fact that they think they're going to become more popular and more secure in their electoral basis by doing this.

Holly Jarman: 7:22

So great. That's, that's the second lesson, really, then if you want to change policy, you have to understand the motivations of the people with decision making power. And it's not to say that some folks couldn't be great elected representatives and wonderful people and might stand for some of the things that public health would like to see, it just means that every elected representative really has to grapple with these questions of how do I stay in office?

Scott Greer: 7:52

And you have to think about how to make the case for your policy idea, based on what they have to try to do and what their strategies are to do something. Are they trying to get promoted to higher office? Are they trying to make a name from the cells as experts in the field? Are they trying to survive a contested primary or a contested general election? What do they want to be known for? What do they think is going to work for them? We talk about political will as if a politician is just struck by lightning and decides to dedicate their career to promoting your idea. Nothing of the sort, the politician is convinced that this policy idea will do something for them.

Holly Jarman: 8:28

Right? I'm a, someone who thinks carefully about systems and structures. And so politicians are embedded in systems and structures, they have incentives to act in particular ways. Okay, so we've got the policy stream, we've got the politics stream. And then the third one is the problem stream. Isn't that a bit obvious that we know what a problem is?

Scott Greer: 8:50

Well, no, I mean, for a start, always figure out whose problem it is and what the problem is. And here's the thing is that your average political decision maker, because they're key, they drive a lot of the agenda. They certainly drive a lot of the decisions, they could spend all their days and nights meeting Policy Advocates with good ideas. And they have an infinite number of political strategies that they could adopt on a lot of issues. So what tends to shape the agenda, what filters out the policy ideas that are gonna get anywhere and the political strategies that are gonna get anywhere is the problem and sometimes the problem is just overwhelming. In 2020, we had the largest pandemic in the west of our living memories, and we also had the largest demonstrations by any indicator we have in American history. Those two issues have absolutely drove the agenda. And as I said, Good luck to you if your account bad your policy ideas, having something to do with either the pandemic or Black Lives Matter in 2020. But a lot of the time, the problem is much more sort of hazy and amorphous. For example, making a problem out of homelessness is a political act. Sometimes it's data sometimes to its lightning strikes, things like an airplane crash can cause an interest in airplanes safety and regulation and so forth. So the problem has very few people who professionally create it. Sometimes it's created by happenstance, sometimes it's created by the media, and sometimes very successful advocates get lucky and managed to create what is widely recognized as a problem.

Holly Jarman: 10:21

Yeah, I think tobacco control is an example of that, because for a long time, smoking was not considered a problem, and research and observations by health researchers and doctors who had noticed that their patients were getting sick in various ways. And we're all smokers, over time, developed enough of an argument and enough of an evidence base that this they managed to shape an argument that, yeah, smoking is a problem. And so that's an example of a success. But I get what you're saying one of the issues here is, what if my problem or the thing that I'm seeing in my community or my state, or in my family is is not widely considered as a problem for the the agenda something that should be prioritised?

Scott Greer: 11:13

Well, a lot of the time, what you're talking about is what we regard as a condition. And the distinction between a problem and condition as simply as that a condition is normalized. So for example, the poor shall always be with you. It is accepted that there's going to be some level of poverty, that's a condition nobody's trying to wipe out poverty and contemporary American politics. But individual dimensions of poverty can get turned into problems. And they frequently do housing insecurity, food insecurity, homelessness, lack of access to health care, these are sort of more manageable, and they look different, and you can portray them differently. And you can identify policy responses, because within the realm of of current American politics, there's no policy that would eliminate poverty, which is really on the map. But there's a lot of policies which address particular manifestations and causes of poverty, which can get onto the agenda, because you can see the policy idea the politician, and a definition of poverty is a problem that shows up in homelessness, for example.

Holly Jarman: 12:15

So why do some conditions become problems, while other conditions in society are ignored like that, like widespread poverty?

Scott Greer: 12:24

Well, that's the policy stream for you. It's a mixture of things like data releases, that suddenly make us say it's a problem. individual events, for example, part of the tracking of homelessness is simply that it's very, very visible problem in a number of cities that are influential in setting the national mood. And a lot of it has to do with luck, bad data releases, Russia invades Ukraine, global pandemic, George Floyd, these all are events that you really could not have predicted would have happened when they did and with the particular impact that they did.

Holly Jarman: 12:59

So we've got three streams, we've got a policy stream, a politics stream, and a problem stream. And we've discussed a bit about some of the ways in which these interact. But doesn't kingdoms theory tell us something more than about how these things come together to create, to really put an issue on the agenda.

Scott Greer: 13:21

Kingdon call that coupling when the three streams come together. So when you have political impetus, politicians who think that they can get ahead by promoting something on this agenda, when they have nice concrete policy ideas that they can work with. And when there's a problem, that means they're going to get attention and some traction by picking up this issue. That's when it gets on to the agenda. So that's when you see, for example, things that have been around forever problems that have been conditions forever and suddenly became problems come together with politicians who had been talking about something else come together with policy ideas that had been down in the bottom of somebody's desk drawer for eight for years, possibly decades. Now, what's sad, is if you only have two, if you have policy ideas and interested politicians, but no problem, you tend to get shoved off the agenda. If you have politicians who want urgently to address a problem, but no policy idea, well, eventually it'll just dissipate in symbolic actions. I think we've seen plenty of that. And when you've seen policy, and when you've seen a policy and a problem. Well, that's like every day in a school of public health. You know, we have avalanches of articles about here's a problem, and here's my idea for solving it. But if you can't figure out how you're going to get a politician to think that this is a workable way to advance their career and make a mark on the world, well, then you might as well save your breath. So you have to get the three together. That opens the window of opportunity for what we really want, which is policymaking, which is legislation.

Holly Jarman: 14:52

So if I'm an advocate, and I'm looking at this framework, well for one thing, that I can reflect on how Often these three streams don't come together. And I think that's quite important to know. But how do I try to figure out these streams in the context of a policy problem? What action should I be taking?

Scott Greer: 15:13

The biggest one? First of all, if you're a policy, if you're if you're interested in policy, first of all, is get good policies and get them vetted, make them make sense, phrase them in ways that are interpretable, to people who care about budgets and legislation, and so forth. hand waving is a good way to get yourself gently pushed out of the policy community have a policy second thing is persist. Look at climate change. We had an enormous number of ideas that were being kicked around and developed and suggested in legislation and discussed in hearings and tried out at the state and local levels, or pilots or internationally. Finally, one gigantic bill in 2022, pushed a bunch of them into actual policy after decades of frustration. And furthermore, the 2022 being an extremely big legislative year, there were other pieces of legislation like on semiconductors, which turned out to include climate change ideas that have been getting pushed around. Over and over again, you see this where the thing about politics is that it because it's probability, and it's a very low scoring game, you always want to be present. Think of it as being like soccer, or European football, where you most of the time, these games are like one nil. So you play and you play, and you play, and you play, and you play. And it's mostly basically frustration and heartbreak. And then finally, somebody pulls something off,

Holly Jarman: 16:29

hang on a minute, no, that's just the men's game, the women's game is pretty high scoring. But that's my caveat.

Scott Greer: 16:36

I leave it to our listeners to figure out the implications of that gender analysis. But most of the time, it's about frustration. I'm talking about the ability to work on your ideas and try to sell people on them and build coalitions and explain why they address a current problem. You do it for decades. And then finally, you catch the wave surfers were the chosen metaphor that Kingdon used where a lot of the time they're paddling around looking a little bit silly. And then they catch a wave and something beautiful can happen. So you want to persist, you want to pay attention to politics, you want to focus on working with people who are fully in the game, and can understand these politicians. So it's not just you on your lonesome with an idea, and a conviction that there's a problem and frustration at the lack of political will. And finally, you're going to encounter this framework a lot. Our mid career students, when they come back to us frequently, where they say this is the one framework that is constantly used in kind of ordinary conversation and health policy. The three streams are about as entrenched as cost quality and access, for example, kind of ordinary language. But it's very, very often done with two mistakes. And here's your health warning. Don't do it. First of all, don't do it all from the point of view of the policy entrepreneur, having a good policy and framing for it is one thing. But you depend on identifying a problem and catching that wave and on having politicians not who care deeply about what you do, but who are going to benefit from it, who are going to get reelected from adopting your policy idea and pushing it. And secondly, getting on the agenda isn't the same thing as being decided the agenda of a meeting is not the same thing as its final minutes. So yeah, you can be discussed, they discussed cap and trade is an approach to climate change all sorts of times in Congress. And does America have cap and trade legislation? emphatically? No. So getting on the agenda isn't the same thing is happening. So those are the two health Warnings Don't think about it as entirely the volition and skills of the policy entrepreneur. Think about it as also including the political weather and the problem stream. And don't ever confuse getting on the agenda with passage.

Holly Jarman: 18:54

This has been an HMP Governance Lab podcast. If you're interested in learning more about our research, come and find us at www dot governance lab.org or follow us on Twitter at HMP. Gov