At the beginning of this chapter we examined a number of factors that affect policy making in Congress. These factors were structure and process, and elections. How well do they explain health policy outcomes in the 103d and 104th Congresses?
Start with structure. We noted differences between the House and the Senate. The House, the larger body, was characterized by more frequent elections and reliance on rules to guide the process. The Senate was more informal, with fewer limits on debate and amendment and more freedom to individual members.
We also looked at the impact of the budgeting process and the budget deficit on policy making. Two important points were made here. First, there was a mechanism, reconciliation, for making significant budget cuts. Second, the PAYGO rule prohibited new programs unless they were budget- deficit neutral, meaning new revenues or other program cuts had to be found. This budget-deficit politics would work against new programs (such as national health insurance) and in favor of program cuts (e.g., Medicare and Medicaid).
The third element of structure involved committees. Committees are where much of the detail work of Congress is done. But the fragmentation of power and authority in Congress meant that complex plans, such as comprehensive health care reform, would be the subject of multiple jurisdictions. For cutbacks in a single program, such as Medicare, multiple jurisdictions were less important.
The other major area discussed focused on elections and related factors such as divided government, gridlock, and realignment. Members of Congress react to the imminence of elections because of their desire to be reelected and to maintain or gain control of the House or Senate. Much of the electoral history of the United States in the post-World War II era has produced divided government, where one party controls the presidency and the other controls one or more houses of Congress. Divided government exacerbates the institutional jealousies created by the constitutional system of separation of powers/checks and balances. The result can be, though it is not always true, gridlock, an inability to make policy. We suggested that the real issue was whether a working majority existed in a particular legislative body. Finally, realignment appeared to increase the ideological coherence of the political parties, making compromise more difficult.
All these factors were important in explaining health care outcomes. While Democrats had a numerical majority in the House and the Senate during the 103d Congress, they did not have a working majority. There was