What Health Reform Tells Us about American Politics.

The passage and initial implementation of the Affordable Care Act (ACA) were imperiled by partisan divisions, court challenges, and the quagmire of federalism. In the aftermath of Republican efforts to repeal the ACA, however, the law not only carries on but also is changing the nature of political debate as its benefits are facilitating increased support for it, creating new constituents who rely on its benefits and share intense attachments to them, and lifting the confidence of Americans in both their individual competence to participate effectively in politics and that government will respond. Critics from the Left and the Right differ on their favored remedy, but both have failed to appreciate the qualitative shifts brought on by the ACA; this myopia results from viewing reform as a fixed endpoint instead of a process of evolution over time. The result is that conservatives have been blind to the widening network of support for the ACA, while those on the left have underestimated health reform's impact in broadening recognition of medical care as a right of citizenship instead of a privilege earned in the workplace. The forces that constrained the ACA's development still rage in American politics, but they no longer dictate its survival as they did during its passage in 2010.

Affordable Care Act Moving to New Stage of Public Acceptance.

The Affordable Care Act (ACA) was enacted in a deeply polarized context, and it has endured multiple challenges to its implementation and its very existence that continue to this day. Yet, we find that the law is entering a new phase of acceptance among the American public, such that it presents political risks to politicians who would dare to weaken it. We have conducted a panel study of Americans' public opinion on the ACA since 2010, returning to the same respondents every two years to ask the same questions. This approach, which is essential for tracking change, reveals that support for the ACA is growing and the most intense opposition is receding. It also shows that Americans' sense of the law's impact on their lives is at least holding steady and in some respects growing. Most strikingly, those who feel favorably toward the law are more engaged politically than those who oppose it, and they are more likely to take it into account when they vote. These trends indicate that the law, despite the legal and political obstacles it still confronts, is becoming more firmly established in public opinion and through patterns of political participation.

The Future of Health Care Reform: What Is Driving Enrollment?

Against a backdrop of ongoing operational challenges, insurance market turbulence, and the ever present pull of partisanship, enrollment in the ACA's programs has soared and significant variations have developed across states in terms of their pace of coverage expansion. Our article explores why ACA enrollment has varied so dramatically across states. We explore the potential influence of party control, presidential cueing, administrative capacity, the reverberating effects of ACA policy decisions, affluence, and unemployment on enrollment. Our multivariate analysis finds that party control dominated early state decision making, but that relative enrollment in insurance exchanges and the Medicaid expansion are driven by a changing mix of political and administrative factors. Health politics is entering a new era as Republicans replace the ACA and devolve significant discretion to states to administer Medicaid and other programs. Our findings offer insights into future directions in health reform and in learning and diffusion.

Interest Group Conflict Over Medicaid Expansion: The Surprising Impact of Public Advocates.

OBJECTIVES: We examined the potential economic, policy, and political influences on the decisions of the 50 US states to expand Medicaid under the Affordable Care Act. METHODS: We related a measure of relative state progress toward Medicaid expansion updated to 2015 to each state's economic circumstances, established policy frameworks in states, partisan control of state government, and lobbyists for businesses, medical professionals, unions, and public interest organizations. RESULTS: The 9201 lobbyists working on health care reform in state capitols exerted a strong and significant impact on Medicaid expansion. Controlling for confounding factors (including partisanship and existing policy frameworks), we found that business and professional lobbyists exerted a negative effect on state Medicaid expansion and, unexpectedly, that public interest advocates exerted a positive effect. CONCLUSIONS: There are 3.1 million adults who lack coverage because they live in the 20 states that refused to expand Medicaid. Although political party and lobbyists for private interests present significant barriers in these states, legislative lobbying on behalf of the uninsured appears likely to be effective.

Why states expand Medicaid: party, resources, and history.

After the passage of the Patient Protection and Affordable Care Act in March 2010 and the affirmation of its constitutionality by the Supreme Court in 2012, key decisions about the implementation of health care reform are now in the hands of states. But our understanding of these decisions is hampered by simplistic sortings of state directions into two or three simple, rigid categories. This article takes a different approach--it tracks the variations in relative state progress in implementing Medicaid expansion across a continuum of activities and steps in the decision-making process. This new measure reveals wide variation not only among states that have adopted Medicaid expansion but also among those that have rejected it but have also made progress. We use this new measure to spotlight cross-pressured Republican states that have adopted Medicaid expansion or have prepared to move forward and to explore possible explanations for implementation that extend beyond a simple focus on party control.

Why public opinion changes: the implications for health and health policy.

Research on stasis or change in public opinion toward health, health policy, and medical care tends to focus on short-term dynamics and to emphasize the impact of discrete messages communicated by individual speakers in particular situations. This focus on what we term "situational framing," though valuable in some respects, is poorly equipped to assess changes that may occur over the longer term. We focus, instead, on "structural framing" to understand how institutionalized public health and health care policies impact public opinion and behavior over time. Understanding the dynamics of public opinion over time is especially helpful in tracking the political effects of the Patient Protection and Affordable Care Act of 2010 as it moves from the debate over its passage to its implementation and operation.

Liking Health Reform But Turned Off By Toxic Politics.

Six years after the Affordable Care Act (ACA) became law, the number of nonelderly Americans with health insurance has expanded by twenty million, and the uninsurance rate has declined nearly 9 percentage points. Nevertheless, public opinion about the law remains deeply divided. We investigated how individuals may be experiencing and responding to health reform implementation by analyzing three waves of a panel study we conducted in 2010, 2012, and 2014. While public opinion about the ACA remains split (45.6 percent unfavorable and 36.2 percent favorable), there have been several detectable shifts. The share of respondents believing that reform had little or no impact on access to health insurance or medical care diminished by 18 percentage points from 2010 to 2014, while those considering reform to have some or a great impact increased by 19 percentage points. Among individuals who held unfavorable views toward the law in 2010, the percentage who supported repeal-while still high, at 72 percent-shrank by 9 percentage points from 2010 to 2014. We found that party affiliation and distrust in government were influential factors in explaining the continuing divide over the law. The ACA has delivered discernible benefits, and some Americans are increasingly recognizing that it is improving access to health insurance and medical care.

Post election, the Affordable Care Act leaves the intensive care unit for good.

Pitched battles over aspects of the law will continue, but the fundamental reality is that stakeholders are fully engaged, and implementation will move ahead.

In the wake of the Supreme Court decision, many stakeholders still support the Affordable Care Act.

In the aftermath of the Supreme Court decision largely upholding the constitutionality of the Affordable Care Act, many stakeholders have renewed their commitment to health care reform. In fact, a new political economy of health care has emerged that is characterized by three dynamics. One is the "log-rolling" dynamic of distributive politics, as evident in mutually supportive efforts for maintenance and expansion of subsidies and other opportunities to advance the interests of stakeholders. A second is the cut-throat zero-sum politics of interest-group conflict, as evident in the intense competition among stakeholders for limited resources and authority. The third dynamic is the result of the emotional and ideological conflicts of resource redistribution. These new dynamics may make repeal of reform more daunting than expected.

The Medicare approach: political choice and American institutions.

The most significant health reform in American history was the passage of Medicare in 1965, but this was an accomplishment born of defeat. Medicare was designed and understood by its early promoters as an approach to health reform, not simply as a discrete program for a distinct target population. Although Medicare incrementalism has tended to be shunted aside when the opportunities for health reform are most promising, the final years of the Johnson administration reveal previously underappreciated efforts to expand Medicare eligibility to large new population groups and offer insights into the continuing potential of Medicare incrementalism in our own time.