Fact: As a nation, medical care expenditures represent 10.6% of the gross national product. The portion of the nation's medical care dollar coming from federal sources declined slightly (42.6% to 41.4%) between 1981 and 1984, but this share is more than 15 percentage points above the comparable figure from the years prior to 1965 (Anderson, 1985).

As these numbers illustrate, paying for health care is a very expensive proposition in the United States, consuming a higher proportion of our nation's resources than is true for most developed nations. While we have strongly resisted any move to a government-run system of health care delivery, the above numbers also show clearly that the federal government pays for a substantial share of all health care in this country.

Three major themes have dominated the health policy agenda during recent years: access to health care, cost containment, and quality of care. The fates of these issues have waxed and waned over the years as changes in health care delivery, federal budgetary politics, and shifting public opinion have altered the environment over time. In the 1960s, access was the key issue, as Democratic administrations used government programs to make health care more readily available to all Americans. As inflation levels soared in the 1970s, cost containment was forced onto the agenda, resulting in a series of attempts to reduce federal expenditures on hospital care. Finally, by the mid-1980s, cost containment pressures were modifying slightly; we have recently witnessed a return to access issues and the emergence of quality as a new political issue.

In 1965, when Medicare and Medicaid were enacted, concern about access to the health care system for the elderly and poor overrode concerns about cost. The legislation focused on removing financial barriers to health care for these groups, and implementation of the legislation was a matter of reaching agreements with hospitals and physicians over reimbursement and administrative procedures with the objective of insuring that health care resources would be available to the beneficiaries of these new federal health insurance programs (Wolkstein, 1984).

Ideological conflict and the alignment of interest groups are central to understanding the politics of Medicare. The intense disagreement over public versus private financing of medical care, and of universal coverage versus covering only the needy (i.e., social insurance versus charity), were key points of contention that established the context within which Medicare and Medicaid were developed, debated and enacted. Labor unions led the liberal organizations and those representing the elderly in advocating a universal, non-income tested federal health insurance system. The American Medical Association (AMA) led the health industry, business and conservative groups in opposing federal financing of personal health care. The intense opposition of the health providers and political conservatives to a universal federal insurance system led the national health insurance advocates to shift to an incremental strategy, the objective of which was to achieve a universal federal health insurance program in stages, beginning with a payroll-tax-financed Medicare program covering all (not just low income) elderly who were eligible for social security pension benefits.

Proposals to reform the presidency fall into three increasingly exclusive categories. The most inclusive are those that focus on reforming the American political system and by doing so altering the balance of power within the government, usually in favor of the chief executive. The effort to strengthen the party system is probably the most prominent representative of this orientation. Other proposals, such as a presidential item veto, would increase the president's power on a more modest scale but still require change in the fundamental rules of the game.

A second class of proposals has the narrower aim of reforming the presidency as an institution. Rather than emphasizing increased power for the president, these recommendations attempt to aid the chief executive in carrying out his responsibilities more judiciously. They often focus on providing the president more or better decision-making resources. Plans for reorganizing or otherwise improving the White House staff system or the Executive Office of the President or for insulating the president from parochial demands through a single six-year term are notable examples of suggestions for institutional reform.

The variety of reformist proposals that is most common and most restricted in scope concentrates on improving the presidency by changing the characteristics of the individuals who occupy the Oval Office. Some would have us pay more attention to the character or personality of candidates for the office, while others stress the importance of choosing presidents who possess the proper skills for governing. To achieve these goals, proponents of change advocate reforms ranging from alterations in the processes by which we select presidents to candidate psychoanalysis.

Changes in the composition of the Supreme Court perhaps inevitably invite speculation about whether and how the Court will change, and what direction it will take in the future. The move of William Rehnquist from associate justice to chief justice and the addition of Antonin Scalia certainly alters the chemistry of the Court. These changes may also have a profound impact on the Court's place in American government during the rest of this century.

There is no doubt that the Court will change. Differences are already apparent during oral arguments. Rehnquist is sharper, more thoughtful, more commanding and wittier than his predecessor in the center chair. And from the far right of the bench, Scalia almost bubbles over with energy and questions for counsel. No less revealing is that in the week before the start of the 1986–87 term on the first Monday in October, Rehnquist managed to get the justices to dispose of over 1,000 cases (granting 22 and denying or otherwise disposing of the rest). He did so in only two days, whereas it usually took Burger more than twice as long to get through about the same number.

Recent events have rendered the politics and governance of the American presidency a source of scorn and derision. While the nation seeks to come to terms with problems of the most serious magnitude in domestic and foreign affairs, the incumbent of the nation's highest office is crippled by a byzantine arms scandal. Moreover, the candidacy of the opposition's “front-runner” for the 1988 presidential nomination has been derailed by a scandal sufficiently salacious to displace as the focus of the media's attention the first week of congressional hearings that are investigating the Iran-Contra affair.

These developments represent an extraordinarily sharp shift in perceptions about the state of the presidency and American politics. Until the Iran-Contra revelations, many statesmen and scholars credited the Reagan Administration with suspending the paralysis that seemed to grip the nation during the post-Watergate years. For example, a survey of political scientists carried out by the National Journal in 1985 revealed that even many scholars who opposed Reagan's policies granted that the president had shown impressive leadership ability in dominating the government's agenda and mastering the Congress (National Journal, April 6, 1985, 743–747). Yet the Iran-Contra affair has apparently spoiled the Reagan legacy, belying the prospects for an enduring restoration of the presidency and a renewed sense of national purpose. The rapid demise of Senator Hart's candidacy reaffirmed that presidential politics was once again mired in issues of personality and institutional disarray. Indeed, the extreme scrutiny of Hart's “private” activities highlighted the ongoing lack of commitment in American politics to a public philosophy, as well as the absence of institutional strength necessary to cultivate and sustain a coherent sense of national purpose (Brinkley, 1987).

As many political humorists remind us regularly, politics “inside the Beltway” is not always of interest or relevance to the rest of the world. Yet for political scientists interested in the ongoing evolution of America's health care system, what goes on inside the Beltway has great import. For any proposed reform, there are three basic steps: getting the issue on the political agenda, securing passage of pertinent legislation, and implementation (although we intend to narrow our discussion to the first two).

A common criticism of academic political science is the disparity between the textbook portrayal of policymaking and the reality of what happens in Washington. In this article, we use abbreviated case studies to inject a dose of “inside the Beltway” reality into the images of policymaking. Included in our discussion is an account of how one issue—catastrophic health insurance—reached the political agenda and then more general comments on how health legislation has been considered and passed in recent years, with particular emphasis on the use of the budget reconciliation process. While cursory, we think these reflections provide a thumbnail sketch of how Washington is attending to important issues of health policy.

For eighteen years, Supreme Court watchers have been waiting for the other shoe to drop. Under Chief Justice Earl Warren in the 1960s, the Court expanded legal protections for civil liberties far more than it had in any previous period. After Richard Nixon was elected president in 1968, many observers expected that his appointments would move the Court away from its commitment to civil liberties. When Nixon was able to appoint four new justices in his first three years in office, that expectation was strengthened. Since that time, each presidential election victory and each Supreme Court appointment by a conservative Republican has led to new hopes and fears that the Cout would abandon its strong support for civil liberties.

To a degree, these expectations already have been realized. Without doubt, the Supreme Court under Warren Burger was less supportive of civil liberties than it had been under Earl Warren. But it did not take the clear conservative position that many Court watchers had anticipated. Reflecting their surprise, a 1983 book about the Burger Court was subtitled, “The Counter-Revolution That Wasn't” (Blasi, 1983).

We know that the abuse of power may cause an erosion of authority, but I would suggest that the current “crisis” over Iran and the Contras confirms a notably different lesson: It is the erosion of authority, or the denial to the president of his rightful, constitutional powers, which has produced a stream of factitious crises. The “scandals” are generated by the prospect of an uncontained president, who is seeking to evade the restraints of the law, in order to deploy the instruments of violence in foreign policy. But the president appears to be bent on a course of lawlessness, he seems persistently to be threatening a “constitutional crisis,” only if one accepts the premise that these statutory restraints on the president are eminently reasonable and constitutional. If they are not, then there is no pattern of lawlessness on the part of the president, no scandal, no crisis.

One commentator has recently remarked that the War Powers Act and the Boland amendment have been parts of a design to “criminalize” differences in policy between Congress and the president. A president who took seriously his responsibilities under the Constitution, or a president who sought to exercise the powers that his predecessors have routinely exercised, would be compelled to steer around these restrictions. When he does, he will be charged with putting himself “above the law.” The opposition party, and its allies in the media, will express their outrage and declare the presence of another “scandal.” There will be calls for a special prosecutor, for a select congressional committee to hold extended hearings—in short, the whole script and the stage directions for Watergate, called into play once again. We now have a part of the political class, in government and the media, who have made “deploring” into a vocation: Their main competence has been cultivated in the art of investigating and holding long, debilitating hearings, with the object of bringing down the Administration or rendering the government of the day ineffectual.

“You could tell by their blank faces that most of them had no idea what the provisions really meant.” Using almost these identical words, two different congressional staff members described two separate groups: (a) the members of a congressional committee considering a Medicare reform provision at a committee mark-up and (b) the personal staff of these same members at a briefing on the provision prior to the mark-up. So what can we conclude about the level of information in Congress? Has the massive expansion of congressional information resources over the past two decades—including vast increases in the number of personal and committee staff and support agency personnel—been for naught?

During the past three years, I have been conducting a study of the approach taken by members and staff of Congress in learning about policy issues and the implications of that approach for congressional decisionmaking. In the fall of 1984, I selected several discrete health and transportation issues which seemed likely to receive significant attention over the entire two years of the 99th Congress. My strategy was to study, for each issue, a sample of congressional “enterprises”—each made up of a member of Congress and his or her staff—as they followed and became involved in the development of the issue. My interest was in communication about these issues both within each enterprise and among all the various enterprises. At this point, nearing the conclusion of the fieldwork, I have conducted over 300 interviews, including meeting with certain key staff members as often as six times in order to monitor their evolving understanding of the issues.