Policy Feedback and the Politics of the Affordable Care Act

There is a large body of literature devoted to how “policies create politics” and how feedback effects from existing policy legacies shape potential reforms in a particular area. Although much of this literature focuses on self‐reinforcing feedback effects that increase support for existing policies over time, Kent Weaver and his colleagues have recently drawn our attention to self‐undermining effects that can gradually weaken support for such policies. The following contribution explores both self‐reinforcing and self‐undermining policy feedback in relationship to the Affordable Care Act, the most important health‐care reform enacted in the United States since the mid‐1960s. More specifically, the paper draws on the concept of policy feedback to reflect on the political fate of the ACA since its adoption in 2010. We argue that, due in part to its sheer complexity and fragmentation, the ACA generates both self‐reinforcing and self‐undermining feedback effects that, depending of the aspect of the legislation at hand, can either facilitate or impede conservative retrenchment and restructuring. Simultaneously, through a discussion of partisan effects that shape Republican behavior in Congress, we acknowledge the limits of policy feedback in the explanation of policy stability and change

How Intense Policy Demanders Shape Postreform Politics: Evidence from the Affordable Care Act

The implementation of the Affordable Care Act (ACA) has been a politically volatile process. The ACA\u27s institutional design and delayed feedback effects created a window of opportunity for its partisan opponents to launch challenges at both the federal and state level. Yet as recent research suggests, postreform politics depends on more than policy feedback alone; rather, it is shaped by the partisan and interest-group environment. We argue that “intense policy demanders” played an important role in defining the policy alternatives that comprised congressional Republicans\u27 efforts to repeal and replace the ACA. To test this argument, we drew on an original data set of bill introductions in the House of Representatives between 2011 and 2016. Our analysis suggests that business contributions and political ideology affected the likelihood that House Republicans would introduce measures repealing significant portions of the ACA. A secondary analysis shows that intense policy demanders also shaped the vote on House Republicans\u27 initial ACA replacement plan. These findings highlight the role intense policy demanders can play in shaping the postreform political agenda

Pension reform in the UK : re-casting the public/private mix in pension provision 1997-2000

The UK is one of the few countries in Europe that is not facing a serious pension crisis. The reasons for this are straight forward: state pensions (both in terms of replacement ratio and as a proportion of average earnings) are among the lowest in Europe, the UK has a long-standing funded private pension sector ... and its governments have, since the beginning of the 1980s, taken measures to prevent a pension crisis developing. These measures have involved making systematic cuts in unfunded state pension provisions and increasingly transferring the burden of providing pensions to the funded private sector, principally on a defined contribution basis

The Constrained Left and its Adverse Impact on Losers of Globalization. IHS Political Science Series No. 120, May 2010

This paper examines the political mechanisms of welfare state policymaking in two countries with differing levels of institutional and political constraints, Germany and Ireland. The study analyzes the joint impact of political constraints and varying party governments on different dimensions of labor market policymaking. It comes to the conclusion that left-wing governments must cut spending more to accommodate the conservative opposition and gain its support when political and institutional constraints are high. To simultaneously ensure the support from pivotal extra-parliamentary actors, namely labor unions that are closely linked to the governing party, the left has to further compensate the unions' prime constituency, which is the well-integrated core workforce. The privileged treatment of labor market 'insiders' by left-wing governments in countries with high political constraints comes at the expenses of labor market 'outsiders'. Left-wing party governments in countries where political constraints are low are better able to address the needs of broader segments of society

Republican States Bolstered Their Health Insurance Rate Review Programs Using Incentives From the Affordable Care Act.

The Affordable Care Act (ACA) included financial and regulatory incentives and goals for states to bolster their health insurance rate review programs, increase their anticipated loss ratio requirements, expand Medicaid, and establish state-based exchanges. We grouped states by political party control and compared their reactions across these policy goals. To identify changes in states rate review programs and anticipated loss ratio requirements in the individual and small group markets since the ACAs enactment, we conducted legal research and contacted each states insurance regulator. We linked rate review program changes to the Centers for Medicare and Medicaid Services (CMS) criteria for an effective rate review program. We found, of states that did not meet CMSs criteria when the ACA was enacted, most made changes to meet those criteria, including Republican-controlled states, which generally oppose the ACA. This finding is likely the result of the relatively low administrative burden associated with reviewing health insurance rates and the fact that doing so prevents federal intervention in rate review. However, Republican-controlled states were less likely than non-Republican-controlled states to increase their anticipated loss ratio requirements to align with the federal retrospective medical loss ratio requirement, expand Medicaid, and establish state-based exchanges, because of their general opposition to the ACA. We conclude that federal incentives for states to strengthen their health insurance rate review programs were more effective than the incentives for states to adopt other insurance-related policy goals of the ACA

None of the Laws But One

This Symposium contribution explores differences in how congressional Republicans responded to Medicare and how they responded to the Patient Protection and Affordable Care Act (ACA). Given the narrowness of the constitutional challenges to the ACA that congressional Republicans promoted and the many federal taxes, expenditures, and regulations that they support, this Article rejects the suggestion that today\u27s Republicans in Congress generally possess a narrow view of the constitutional scope of federal power. The Article instead argues that congressional Republicans then and now-and the two parties in Congress today-fracture less over the constitutional expanse of congressional authority and more over the political objectives that robust federal power will be used to accomplish. Accordingly, the key question going forward is not one of perceived constitutional limits on Congress, but whether the federal government will expand or even maintain its role in combating economic vulnerability, a role that President Lyndon Johnson\u27s Great Society performed to a significant extent by transforming America from a regulatory state to a welfare state

Groping for Autonomy: The Federal Government and American Hospitals

This article chronicles the slow but steady emergence of countervailing power in the hospital industry since mid-century. The transformation of American health care policymaking reflects the federal government\u27s growing fiscal obligations as the single largest purchaser of health care. As John Kenneth Galbraith [1956,113] notes, Power on one side of a market creates both the need for, and the prospect of reward to, the exercise of countervailing power from the other side. The federal government\u27s effort to exercise countervailing power over health care providers shows no sign of abating in the future, for Medicare and Medicaid costs threaten the stability of the balanced budget agreement negotiated by the Clinton administration and the Republican leadership of the 105th Congress

Georgia: Individual State Report - State-level Field Network Study of the Implementation of the Affordable Care Act

This report is part of a series of 21 state and regional studies examining the rollout of the ACA. The national network -- with 36 states and 61 researchers -- is led by the Rockefeller Institute of Government, the public policy research arm of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania.According to the report, much of the reduction in Georgia's uninsured population can be attributed to the extensive education and outreach efforts that were carried out by a variety of nonprofit and community-based organizations. Many media organizations also played a role through various public information activities and their extensive coverage of the eligibility requirements, the process for signing up for coverage through the federal health insurance marketplace, and opportunities for obtaining consumer assistance with the enrollment process.Unlike many other states that embraced a more positive response to health reform, Georgia's state government did not engage in any formal education, public information, or outreach activities to assist eligible low-income households in connecting to the most appropriate health insurance plan for their needs and circumstances through the marketplace. The report concludes that while notable gains were made in extending health care coverage to the uninsured during the first two enrollment periods, given the size of Georgia's "coverage gap," further reductions in the state's uninsured population will likely depend on state officials crafting an alternative to Medicaid expansion acceptable to the state's political leadership

West Virginia: Round 1 - State Level Field Network Study of the Implementation of the Affordable Care Act

This report is part of a series of 21 state and regional studies examining the rollout of the ACA. The national network -- with 36 states and 61 researchers -- is led by the Rockefeller Institute of Government, the public policy research arm of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania.As noted throughout this report, West Virginia's experience is a tale of two reforms or experiences. The state has adopted a hands-off, but nonhostile, posture toward the health insurance exchange. Unique policy and political dynamics contributed to the state first embracing the concept of its own exchange and then moving toward a very passive role in a state-federal partnership. In contrast, the state has been proactive in reaching out and enrolling those newly eligible under Medicaid expansion. As ACA implementation gains traction and best practices are discovered and shared, West Virginia's aggressive approach of utilizing SNAP enrollment lists as a means of reaching potential Medicaid applicants may be one of those stories that come to the fore