Developing health policy via direct democracy: Case studies of statewide health care initiatives.

摘要

In the United States, direct democracy is a tool provided in the constitutional framework of twenty-four states and the District of Columbia. Balancing representational democracy, in the last one hundred years it has become a powerful method of policy creation for people interested in overcoming a perceived gridlock. Through initiatives and referenda, policies are introduced to the voting public for their decision. Ballot measures have included a variety of health policy issues, from tobacco taxes to willing provider mandates. Some are multimillion-dollar ventures sponsored by industry interest groups. Others are grassroots efforts organized by concerned citizens. Recent health policy initiatives have addressed the issue of access to health care.;This study examines the initiative process as it applies to the field of health policy and the issues that have shifted the health policy-making process, in some states, from the legislature to the ballot. The analysis begins with an overview of direct democracy, followed by a census of the existing health policy initiatives that have appeared on ballots between 1900 and 2000. Within this census, this study targets initiatives that focus on access to care. Three in-depth case studies are used to illustrate how initiative campaigns, from development to implementation, contain complicated sets of external and internal factors that bring about heightened public discourse. These initiatives are analyzed through institutional, organizational, and individual sources of data. They provide examples of the initiative process as it is used in health policy.;The dissertation concludes with a critical analysis of the use of direct democracy to affect health policy, examining when it is a functionally strategic fit. It concludes that direct democracy, in confronting health policy issues not addressed in the representational forum, raises the level of public debate and moves both citizens and representatives to new understandings of complicated policy decisions. Direct democracy may provide the impetus for change, yet ballot measures do not stand alone, but play a role as a component in representational policy making. Looking at direct democracy through the lens of health policy demonstrates both the challenges and benefits associated with developing policy through the people.