The idea that changes occur incrementally in health policy is not new. In a chapter in Eli Ginzberg's book on American health reform, David Mechanic13
writes, “Experience throughout the world indicates that no health system achieves its full potential in a single leap. Rather, they evolve through iterative stages that reflect accommodations … and an appreciation of the need to fine-tune various financial and organizational features. To the extent that we view health reform as an evolving process, we will have better opportunities to achieve reasonable solutions built around widely shared principles” (p. 51). In the same volume health policy analyst Lawrence D. Brown14
contrasts “fundamental,” “comprehensive,” and “systemic” change models with the model of incrementalism and its concerns for the institutional and bureaucratic “details” that he concludes make all of the difference. Commenting on mental health reform in yet a third chapter in the same book, Goldman, Frank, and McGuire15
describe the “phased-in” approach for including mental health benefits in the Bill Clinton administration plan. Administrative and political obstacles to more comprehensive reform necessitated this explicitly sequential approach to major reform. The “phased-in” reform plan recommended a basic mental health benefit that was better than typical private insurance benefits for the first stage of health reform—to be followed by a more comprehensive benefit package if costs could be controlled.
Tipper Gore, the wife of Vice President Al Gore, had cochaired the Working Group on Health Care Reform that proposed the phased-in benefits for mental disorders. She had strongly preferred the more comprehensive approach and was disappointed in the negative responses she received to the broader reform proposals. Perhaps most shocking to her were the dismissal of the “reality” of mental disorders and serious doubts about the effectiveness of treatment and services expressed by opponents of expanded insurance benefits. Even when bolstered with evidence from research on mental illness, the comprehensive proposals were rejected by the leaders of health care reform. Research documents from professional associations and the NIMH were dismissed as “advocacy” documents (Tipper Gore, personal communication, 1993).
After attending the release of a report of the surgeon general on physical activity and health at the 1996 Olympic Games, Tipper Gore was impressed with the value of the imprimatur of the nation's leading health officer. Immediately, she began the process within the administration that led to the writing of a report of the surgeon general on mental health,4
released in 1999 (Tipper Gore, personal communication, 1999). Although the report did not include specific policy recommendations, it outlined a vision for the future and 8 “courses of action” to improve mental health in the United States. The following 8 courses of action were derived from the scientific review by the surgeon general: (1) continue to build the science base; (2) overcome stigma; (3) improve public awareness of effective treatment; (4) ensure the supply of mental health services and providers; (5) ensure state-of-the-art treatments; (6) tailor treatment to age, gender, race, and culture; (7) facilitate entry into treatment; and (8) reduce financial barriers to treatment.4
The report of the surgeon general4
laid the scientific foundation for reform, and its courses of action suggested a set of directions for the policy recommendations that were to emerge from the President's New Freedom Commission on Mental Health. The commission was formed in April 2002 and worked for 1 year to develop an interim (2002)8
and a final report (2003).5