Incremental Policy Change Research Articles

School Meals for All: A Qualitative Study Exploring Lessons in Successful Advocacy and Policymaking in Maine and California

BackgroundThe COVID-19 pandemic focused national attention on food insecurity, equity, and the role of school meal programs in supporting children, families, and communities. In doing so, the pandemic created a rare policy window—an opportunity to advance a longstanding public health goal of guaranteed access to free school meals for all students. In July 2021, California and Maine became the first states to authorize school meal for all legislation (also known as universal free meals). ObjectiveThe aim of this study was to explore perspectives of policymakers, state agency officials, and advocates on the conditions and mechanisms that facilitated passage of school meal for all legislation in California and Maine. DesignA qualitative case study was conducted. ParticipantsBetween December 2021 and June 2022, semistructured interviews were conducted with 30 policymakers, state agency officials, and advocates. Statistical analysis performedInterviews were analyzed using principles of content analysis. Key themes are organized using Kingdon’s multiple streams framework for public policy. ResultsEleven key themes were identified. Lessons are drawn from the policy and advocacy strategies used to advance laws in California and Maine. For instance, paving the way with incremental policy change, tailoring messaging to diverse audiences, and organizing at the grassroots and grasstops levels were critical to success of advocacy efforts. ConclusionsPromising practices can guide efforts to expand access to school meals and advance other child nutrition policies in other states and nationally. Moving forward, lessons learned from implementation of universal free school meal legislation in California, Maine, and other early adopters should be documented and shared.

The American ‘doc fix’: Incremental policy change and the growth of US healthcare spending

The extraordinary growth of healthcare spending in the United States necessitates an incremental model of institutional change. Efforts to reduce social spending in the 1980s introduced strict cost controls on healthcare, yet this regulation was annually abated with temporary legislation known as ‘doc fixes’. We show that the institutions set up to control spending were slowly undermined through three mechanisms: the transformation of wider political and economic problems into technical ones, the ‘layering’ effect of repeated budgetary appropriations, and the moral arguments that sustained incremental spending growth. This case illustrates how creative responses to budget constraints may produce incremental change, driven by ideas about how markets and welfare should work.

Local Governments, Pandemic Aid, and Community Violence Intervention

Expenditures on police departments account for significant portions of local government budgets in the United States. Yet activism on police reform and changing views on the causes of violence have called into question law enforcement's role in public safety. While intergovernmental transfers have historically supported traditional policing, the American Rescue Plan Act's Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) affords cities the opportunity to disrupt the status quo by providing them with the federal funds and flexibility to reshape their public safety policies around Community Violence Interventions (CVIs). This article examines how 13 cities that participated in a White House convened collaborative used CSLFRF aid to support CVIs. Our analysis reveals significant variation in how these cities in allocated CSLFRF dollars to CVI programs, suggesting that the combination of federal aid and White House encouragement has thus far led to incremental policy changes, whose durability remains an open question.

Understanding radiation treatment terminations as an element of quality.

408 Background: Disruptions in cancer care adversely affect clinical outcomes. The effect is magnified when treatments are not just protracted, but discontinued prematurely. The incidence of such treatment termination (TT) during radiation therapy has not been well studied. We herein present a single-institution cohort of TT at a large multi-center radiation oncology department over 10 years. Methods: As part of our ongoing departmental quality and safety monitoring program, TTs were prospectively tracked and assessed. A TT was defined as the premature discontinuation of therapy at any point following the initiation of radiation planning. The rate of TT was calculated as a percentage of all new patients who start radiation planning. Each TT between 1/2013 and 1/2023 was analyzed for a root cause, reviewed among multi-disciplinary Quality committee members, and presented monthly to the radiation department. Selected cases sparked discussion and efforts to identify interventions that may decrease the likelihood of similar TTs. Incremental departmental policy and procedure changes to critical pre-treatment evaluation, prospective contouring rounds, on-treatment management, and scheduling processes were implemented, collectively referred to as the “No-Fly” policy. Results: A total of 1,467 TTs were identified and analyzed. 688 (46.9%) involved patients treated with curative intent, 770 (52.5%) with palliative intent, and 9 (0.6%) for benign disease. The most common cause of TT was hospice and/or death (36.5%), 69.1% of which were in patients receiving palliative treatments. Other common causes identified are shown in Table 1. The overall 10-year rate of TT was 5.1% (1,467 of 28,707 planned treatment courses). The rate of TT decreased from 9.3% to 3.3% (2013 and 2022, respectively), with rates decreasing at each iteration of No-Fly from 8.8% (No-Fly 1, 2013-2014) to 5.2% (No-Fly 2, 2015-2018) to 4.0% (No-Fly 3, 2019-2022) (ANOVA p<0.001). Conclusions: Premature termination of radiation therapy can be deleterious for cancer patients. Determining the causes of TTs so that they may be mitigated is integral to effectively managing care and improving safety culture in radiation medicine departments. While some TTs may be unavoidable, open discourse and quality improvement changes are effective in reducing incidents over time. Understanding TTs is complimentary to other nationwide projects exploring how reducing missed radiation therapy appointment rates support access to high quality oncology care.[Table: see text]

Moving Toward Inclusion: Access to Care Models for Uninsured Immigrant Children.

Policy Points Models for access to care for uninsured immigrant children that mitigate structural and sociopolitical barriers to inclusive health care include funding structures (e.g., state-sponsored coverage) and care delivery systems (e.g., federally qualified health centers,). Although the quintessential model of access to care necessitates health coverage for all children regardless of immigration status or date of United States entry, incremental policy change may more realistically and efficiently advance equitable access to high-quality health care. Intentional advocacy efforts should prioritize achievable goals that are grounded in data, are attentive to the sociopolitical milieu, are inclusive of diverse perspectives, and would meaningfully impact health care access and outcomes.

Period politics and policy change: the taxation of menstrual products in the United Kingdom, 1996–2021

ABSTRACT How, when and why do policies change? This article engages with this question through a focus on the taxation of menstrual products in the United Kingdom from its initial emergence as an issue in 1996 through to the eventual abolition of the ‘tampon tax’ on 1 January 2021. Despite the significance of this topic for broader debates concerning gender inequality, political efficacy and social change it is not one that has been the focus of close historical analysis. The research presented in this article fills this gap in the existing research base and reveals (inter alia): (i) the ebb-and-flow of the issue-attention cycle; (ii) the grating of domestic pressures against international obligations; (iii) incremental policy change in an attempt to assuage campaigners; (iv) the co-option of ‘period poverty’ as a strategic and symbolic issue by Brexit campaigners; (v) and the eventual resolution of the issue a quarter of a century after it was first raised. As such the politics of policy change vis-à-vis the taxation of menstrual products in the United Kingdom fits within a number of broader debates concerning: how, when and why policies change; the complexities of multi-level governance; and interpretations of policy success and policy failure.

Navigating the grey: Experiences of incremental cannabis reform in Australia.

There have been many changes to cannabis laws across the globe, some dramatic but more often incremental. This study explored the experiences after an incremental cannabis law reform in the Australian Capital Territory, Australia. Semi-structured interviews (n= 30) were conducted in March and April 2021, 14 months after the introduction of cannabis law reform, with people aged 18 and over who had grown and/or consumed cannabis in the previous 12 months. Participants were asked about recent and past cannabis use, growing cannabis and changes to their practices after the introduction of the legislation. Incremental cannabis law change resulted in regulatory grey areas. How people interpreted and navigated such grey areas were connected to their relative privileges, circumstances and histories. Those who were highly policed were more likely to experience the grey areas negatively. Those who were not highly policed found the grey areas confusing or 'half-arse' (insufficiently executed), but mostly experienced the new laws positively through new cannabis cultivation or perceived reduction in stigma and fear of arrest. Those with self-identified privilege were unconcerned with grey areas of the legislation. Incremental policy change can result in grey areas that require some navigation. Vulnerable populations appear less likely to experience the full benefits of such incremental drug law reform. It is vital to attend to the inequities that can arise from incremental law reform so that positive experiences are shared across the population regardless of relative privilege.

Drug Overdose Deaths Reach Grim Milestone During Pandemic

Drug Overdose Deaths Reach Grim Milestone During Pandemic

Tendência à estabilidade institucional: regulação, formação e provimento de médicos no Brasil durante o governo Lula

Abstract This article aims to analyse the characteristics of the regulation, training and supply policies of medical doctors in Brazil, during Lula government (2003-2010), as well as the process of dispute about a policy change proposed by senior officers of the Ministry of Health, who were members of the Health Reform movement. This is a case study that used process tracing as a methodological strategy and, as sources, documents and interviews. We used the theoretical resources offered by studies on political process and the theory of gradual institutional change. The main findings are the understanding of institutional arrangements in this policy, and the identification of individual and collective actors who acted to change the policy. Three political-institutional restrictions to change were found: the opposition of the Liberal Medicine advocates Community, which exerted a political influence on the area, the lack of support or resistance to change from the Ministry of Education and the government nucleus decision not to carry out proposals that, at the same time, had to be approved by the Legislative and had the opposition of the Liberal Medicine advocates Community. A balance tending to reproduce the status quo and the current institutional arrangement prevailed, despite the implementation of incremental policy changes.

A refined experimentalist governance approach to incremental policy change: the case of process-tracing China’s central government infrastructure PPP policies between 1988 and 2017

How public policies change incrementally over time remains understudied. This paper contributes to the studies of incremental policy change by integrating the theories of policy layering and learning into a theoretical framework of experimental governance (EG). Using a mixed research method, we apply this framework to process-tracing the changing trajectory of China’s central government infrastructure public-private partnership (PPP) policies from 1988 to 2017 by looking at evolving policy goals, policy measures, and policy co-issuing networks. Results suggest that China’s central government infrastructure PPP policy change follows a refined EG approach in which policies change incrementally in a layering pattern, primarily driven by learning. Findings provide a new account of incremental policy change.

Impacts of the Clean Air Act on the Power Sector from 1938-1994: Anticipation and Adaptation

The passage of landmark government regulation is often the culmination of evolving social pressure and incremental policy change. During this process, firms may preemptively adjust behavior in anticipation of impending regulation, making it difficult to quantify the overall economic impact of the legislation. This study leverages newly digitized data on the operation of virtually every fossil-fuel power plant in the United States from 1938-1994 to examine the impacts of the 1970 Clean Air Act (CAA) on the power sector. This unique long panel provides an extended pre-regulation benchmark, allowing us to account for both anticipatory behavior by electric utilities in the years leading up to the Act's passage and reallocative effects of the CAA across plant vintages. We find that the CAA led to large and persistent decreases in output and productivity, but only for plants that opened before 1963. This timing aligns with the passage of the original 1963 CAA, which provided the federal government with limited authority to “control” air pollution, but signaled impending federal regulation. We provide historical evidence of anticipatory responses by utilities in the design and siting of plants that opened after 1963. We also find that the aggregate productivity losses of the CAA borne by the power sector were substantially mitigated by the reallocation of output from older less efficient power plants to newer plants. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Impacts of the Clean Air Act on the Power Sector from 1938-1994: Anticipation and Adaptation

The passage of landmark government regulation is often the culmination of evolving social pressure and incremental policy change. During this process, firms may preemptively adjust behavior in anticipation of impending regulation, making it difficult to quantify the overall economic impact of the legislation. This study leverages newly digitized data on the operation of virtually every fossil-fuel power plant in the United States from 1938-1994 to examine the economic impacts of the 1970 Clean Air Act (CAA) on the power sector. This unique long panel provides us an extended pre-regulation benchmark, allowing us to account for both anticipatory behavior by electric utilities in the years leading up to the Act's passage and reallocative effects of the CAA across plant vintages. We find that the CAA led to large and persistent decreases in output and productivity, but only for plants that opened before 1963. The timing aligns with the passage of the original 1963 CAA, which provided the federal government with the authority to control air pollution, sending a strong signal to firms of impending federal regulation. We provide historical evidence of anticipatory responses by utilities in the design and siting of plants that opened after 1963. We also find that the aggregate productivity losses of the CAA borne by the power sector were substantially mitigated by the reallocation of output from older less efficient power plants to newer plants.

The development of EU health policy and the Covid-19 pandemic: trends and implications

ABSTRACT EU health policy is a policy forged in crisis. Whilst maintaining the strict limitations on the EU’s role that are described in the treaties, crises have historically been followed by incremental but integrative policy change. Given this trend, should we be expecting a radical expansion of EU health policy in the aftermath of Covid-19? And, if so, what parameters and characteristics might this new agenda have? As we enter the period in which the EU will try to elaborate its new health policy, this paper uses a Complexity perspective to assess how the emerging agenda compares to existing and historical EU action on health, the kind of decision-making that we are likely to see in the different areas of action, and the limitations of EU health policy development as it pushes into more political and complex areas of policy.

Editorial Introduction: Advances in Theory and Practice of Policy Research from National to Local Level

Editorial Introduction: Advances in Theory and Practice of Policy Research from National to Local Level

Advancing the health of homeless populations through vaccinations.

Homeless individuals and families are at an increased risk for contracting and transmitting communicable infections and diseases. Due to poor living conditions and limited access to health care resources, homeless people of all ages are vulnerable to acquiring communicable infections, such as pneumococcal pneumonia. Less than 40% of sheltered and unsheltered homeless people in South Florida, who were interviewed for this project, knew their immunization status and/or were up-to-date with their recommended vaccine histories. The immunization project implemented a five-step process to provide pneumococcus (pneumococcal polysaccharide vaccine 23) and Prevnar 13 vaccinations to a convenience sample of adult homeless men and women (N = 209) participants, who completed the financial eligibility form (J11) during their intake process to admission, for sheltered services from two local clinics. To promote herd immunity, the five-step process was followed. As per the Centers for Disease Control and Prevention guidelines, initial training was provided to homeless shelter health care providers on vaccine storage, handling, and vaccination. A subsequent 1-week follow-up was completed with participants to determine if any delayed vaccination adverse reactions occurred. Descriptive statistics was used to examine data from the initial project implementation. Findings indicated that more African Americans (n = 117) participated in the project than Whites (n = 50), Hispanics (n = 35), or Haitians (n = 7). Homeless individuals experience illnesses that are preventable through involvement with a structured immunization program. Collectively, nurse practitioners can reduce barriers to immunization by increasing vaccine coverage and introducing incremental policy changes that enhance the health status among homeless populations.

Developing pathways for community-led research with big data: a content analysis of stakeholder interviews

BackgroundBig data (BD) informs nearly every aspect of our lives and, in health research, is the foundation for basic discovery and its tailored translation into healthcare. Yet, as new data resources and citizen/patient-led science movements offer sites of innovation, segments of the population with the lowest health status are least likely to engage in BD research either as intentional data contributors or as ‘citizen/community scientists’. Progress is being made to include a more diverse spectrum of research participants in datasets and to encourage inclusive and collaborative engagement in research through community-based participatory research approaches, citizen/patient-led research pilots and incremental research policy changes. However, additional evidence-based policies are needed at the organisational, community and national levels to strengthen capacity-building and widespread adoption of these approaches to ensure that the translation of research is effectively used to improve health and health equity. The aims of this study are to capture uses of BD (‘use cases’) from the perspectives of community leaders and to identify needs and barriers for enabling community-led BD science.MethodsWe conducted a qualitative content analysis of semi-structured key informant interviews with 16 community leaders.ResultsBased on our analysis findings, we developed a BD Engagement Model illustrating the pathways and various forces for and against community engagement in BD research.ConclusionsThe goal of our Model is to promote concrete, transparent dialogue between communities and researchers about barriers and facilitators of authentic community-engaged BD research. Findings from this study will inform the subsequent phases of a multi-phased project with the ultimate aims of organising fundable frameworks and identifying policy options to support BD projects within community settings.

Deep adaptation to climate change in the maritime transport sector – a new paradigm for maritime economics?

ABSTRACT In recent years a significant body of work has been established on climate change adaptation by ports. Like climate change mitigation, work towards adaptation has stalled on the same collective action problem, whereby public and private sector actors avoid commitment to necessary investments. Recently the concept of ‘deep adaptation’ has appeared, which suggests that, rather than climate change bringing simply incremental challenges that can be adapted to in a piecemeal fashion, in fact, we should expect ‘disruptive and uncontrollable levels of climate change, bringing starvation, destruction, migration, disease and war’. However, current port and shipping forecasts continue to predict uninterrupted growth with only minor incremental policy changes already known to be insufficient for mitigation and adaptation. Thus, this paper argues that actors in the maritime transport sector need to consider greater threats than those currently identified and also prepare for a more advanced adaptation timetable.

Challenging the Welfare System and Forcing Policy Innovation? Unaccompanied Asylum-seeking Children in Sweden and Germany

Abstract The article examines from a comparative perspective how Sweden and Germany reacted to the unprecedented increase in unaccompanied asylum-seeking children (UASC) in 2015. Concretely, it analyses on the basis of Windrum’s taxonomy of public-sector innovation what kinds of generic and context-specific policy instruments have been developed for this particularly vulnerable group and discusses whether and to what extent prevailing welfare-service organizational arrangements have changed in the two countries since 2015. By illustrating the reactions of two countries, the study shows that an unprecedented wave of refugees/asylum seekers can trigger both more incremental, adaptive and drastic transformative policy changes. The policy systems of both countries indicate not only some resilience, but also overburdened government capacity and more drastic changes that led to reduction of the legal rights of UASC.

Examining United States military sexual misconduct policy processes

PurposeSexual misconduct (sexual assault and sexual harassment) in the US military is a long-standing problem. The military has implemented many policies and programs to address sexual misconduct in its ranks. The purpose of this paper is to examine how the processes of military sexual misconduct policy and programs have evolved since the 1940s.Design/methodology/approachPunctuated equilibrium and multiple streams theories were the guiding frameworks for this process analysis of the policies and programs implemented to address military sexual misconduct based on existing literature, news media and press.FindingsThree punctuations are found in military sexual misconduct policy that demonstrate large-scale departures from the periods of equilibrium as the result of either a significant sexual misconduct allegation or new survey findings revealing sexual misconduct prevalence rates. In between these major-issue defining events, incremental policy change has occurred resulting in a period of stasis or return to the status quo requiring correction. Despite returns to stasis, each policy punctuation has built on the prior punctuation, generating new military directives, policies and programs.Originality/valueUsing the lenses of punctuated equilibrium and multiple stream theories, this paper shows how the processes of US military sexual misconduct policies and programs have evolved. The US military and militaries globally can utilize these policy frameworks to help predict future patterns of military sexual misconduct and improve responses to these problems.

Integrating Science, Technology and Health Policies in Brazil: Incremental Change and Public Health Professionals as Agents of Reform

AbstractBrazil has encouraged an ambitious set of policies towards the pharmaceutical industry, aiming to foster technological development while meeting health requirements. We characterise these efforts, labelled the ‘Complexo Industrial da Saúde’ (Health-Industry Complex, CIS), as an outcome of incremental policy change backed by the sustained efforts of public health professionals within the federal bureaucracy. As experts with a particular vision of the relationship between health, innovation and industry came to dominate key institutions, they increasingly shaped government responses to emerging challenges. Step by step, these professionals first made science and technology essential aspects of Brazil's health policy, and then merged the Ministry of Health's new focus on science, technology and health with industrial policy measures aimed at private firms. We contrast our depiction of these policy changes with a conventional view that relies on a partisan orientation of the executive.