Political influence in the 1990s: from iron triangles to policy networks.

To assess the prospects of comprehensive health care reform during the Clinton administration, we must examine the changes that have occurred in the political and structural contexts in which reform is debated. The political context includes the status of the health care system itself as well as public attitudes and voting patterns associated with health care reform; it may be friendlier now to reform than it has been in any previous period, but it cannot on its own produce policy change. The structural context, the representational community of organized interests and government institutions, is the means by which politics is either thwarted or translated into action. Changes in these organized interests and in Congress have transformed the health care reform policy community from an "iron triangle" dominated by an antireform alliance of medicine, insurance, and business to a more loosely bound policy network in which a reform coalition may now be able to prevail, especially under the direction of an activist president like Bill Clinton. I consider three hypotheses: The first claims that, despite the apparent structural changes, the core power relationships will remain the same as in the past, and the antireform alliance either will continue to block policy change or will push through a reform program that protects its constituent interests. According to the second, the structural changes produce an atomization of power, making coalition building in support of reform impossible. The third and most plausible hypothesis proposes that the structural changes, in combination with the shift in politics and Clinton's election, have generated new opportunities for fundamental reform.