Alex Waddan

Implementing health care reform in the United States: Intergovernmental politics and the dilemmas of institutional design

The Affordable Care Act (ACA) was enacted, and continues to operate, under conditions of political polarization. In this article, we argue that the laws intergovernmental structure has amplified political conflict over its implementation by distributing governing authority to political actors at both levels of the American federal system. We review the ways in which the laws demands for institutional coordination between federal and state governments (and especially the role it preserves for governors and state legislatures) have created difficulties for rolling out health-insurance exchanges and expanding the Medicaid program. By way of contrast, we show how the institutional design of the ACAs regulatory reforms of the insurance market, which diminish the reforms political salience, has allowed for considerably less friction during the implementation process. This article thus highlights the implications of multi-level institutional designs for the post-enactment politics of major reforms.

Redesigning the Welfare Contract in Theory and Practice: Just What Is Going on in the USA?

This is the final version as printed by CUP and available at their website http://journals.cambridge.org/action/displayIssue?jid=JSP&volumeId=30&issueId=01

A Liberal in Wolf's Clothing: Nixon's Family Assistance Plan in the Light of 1990s Welfare Reform

When President Clinton signed the Personal Responsibility and Work Opportunity Reconciliation Act ( PRWORA ) in August 1996, it brought to an end the much vilified sixty-one-year-old Aid to Families with Dependent Children ( AFDC ) programme. Although few mourned the passing of AFDC per se many liberals were alarmed by the nature of the changes. AFDC had effectively been a cash maintenance programme for poor single-parent families with the costs shared between federal and state governments. The PRWORA repealed AFDC and some smaller related programmes, with Washington giving its former share of funding to the states in the form of a new block grant, Temporary Assistance to Needy Families ( TANF ). The existing entitlement nature of AFDC was ended with the states given new discretion in determining TANF eligibility. Overall considerable responsibility for the implementation of welfare policy was devolved to the states. The bill, however, did set a maximum time limit for individual receipt of federal TANF funds. After two years, welfare recipients must engage in a recognized work effort to continue to receive help, with a total five-year limit on TANF money. Opposition to these measures was overwhelmed by the demand for significant reform of the welfare system. Previously this demand had been thwarted through a combination of Washington gridlock and the limited scale of those changes which were enacted. In 1996, however, the dam holding back reform was breached at the high tide of anti-welfare sentiment. The despair this provoked among liberals should perhaps have caused them to reflect on their part in blocking previous attempts at an overhaul of AFDC . In particular, the elder statespersons of liberalism might regret their role in helping defeat President Nixons Family Assistance Plan ( FAP ).

Breaking down ideas and institutions: the politics of tax policy in the USA and the UK

As the existing comparative policy literature suggests, both ideational and institutional analyses have clear analytical value in their own terms but, under many circumstances, it is the combination of the two perspectives that allows for a full understanding of policy trajectories. In this article we suggest that, to improve our understanding of how ideas and institutions interact to produce change, it is important to break down these two overly broad concepts. This is because beyond general arguments about how ‘ideas’ and ‘institutions’ interact, students of public policy should itemize ‘ideas’ and ‘institutions’ into more focused, and empirically traceable, subcategories while recognizing the changing and contingent nature of their interaction, over time. To illustrate this, we turn to the politics of tax policy in the United States of America and the United Kingdom, tracking developments from the rise of the New Right and an aggressive income tax cutting agenda, personified by President Reagan and Prime Minister Thatcher, through to the revived debate about the legitimacy of increasing taxes on those earning the highest incomes that emerged in the era of austerity that followed the Great Recession of 2008.

Polarized Stakeholders and Institutional Vulnerabilities: The Enduring Politics of the Patient Protection and Affordable Care Act

PURPOSE We conducted a comparative study of how state-level political stakeholders affected the implementation of 3 major reforms within the Patient Protection and Affordable Care Act (ACA). Our goal was to analyze the effects of policy legacy, institutional fragmentation, and public sentiments on state obstruction of the reform. METHODS We gathered quantitative and qualitative evidence to generate cross-case comparisons of state implementation of 3 reform streams within the ACA: health insurance exchanges, Medicaid expansion, and regulatory reform. Our sources included secondary literature, analysis of official decisions, and background interviews with experts and public officials. FINDINGS We found that state-level opponents of the ACA were most likely to be successful in challenging reforms with few preexisting policy legacies, high institutional fragmentation, and negative public sentiments. Reforms that built on existing state legislation, avoided state veto points or offered lucrative fiscal incentives, and elicited less negative public reaction were less likely to be contested. IMPLICATIONS Our findings point to the importance of institutional design for the role of political stakeholders in implementing reforms to improve the cost, quality, and availability of medical treatments. Although other research has found that political polarization has shaped early ACA outcomes, comparative analysis suggests political stakeholders have had the highest effect on reforms that were particularly vulnerable.

The Obama Presidency and Health Insurance Reform: Assessing Continuity and Change

During the 2008 federal campaign, Democratic presidential candidate Barack Obama placed comprehensive health care reform at the centre of his platform. In the light of the growing problems facing the US health care system, the time seemed ripe for another attempt to control health costs while expanding insurance coverage. Elected in the context of the deepest recession since World War II, President Obama nonetheless decided to reform the US health care system at the beginning of his presidency. Drawing on the historical institutionalist perspective, which stresses the effects of existing institutions and policy legacies on social policy development, this article analyzes health politics during the first fifteen months of the Obama administration before assessing the impact of the legislation enacted in March 2010. Although it does not radically break from the past, this legislation should bring about crucial changes to the US health care system.

The Social Policies Presidents Make: Pre-emptive Leadership under Nixon and Clinton

Grounded in Stephen Skowroneks typology of presidential leadership, this paper furthers our understanding of ‘pre-emptive leadership’ through a comparative analysis of the welfare and Social Security reforms pursued by US presidents Richard Nixon and Bill Clinton. Although not identical, their experience in these areas provides valuable insight into the difficulty of wielding power in an inhospitable political environment. The paper starts with a brief presentation of Skowroneks typology before discussing the electoral strategies employed by both presidents as they attempted to frame political identities that would allow them to compete successfully in unfavourable ideological and political circumstances. The paper then specifically focuses on the politics of welfare and Social Security reform as the two presidents used these issues as part of their efforts to craft distinctive political images and attract wider electoral support. This comparative analysis reinforces the concept of ‘pre-emption’ as a valuable tool in understanding presidential behaviour. However, it also underlines the limits of pre-emptive leadership. Pre-emptive strategies can be effective at election time, but they are less likely to succeed in the legislative arena. This reality complicates the presidential search for genuine policy legacies.

WHY ARE THERE NO UNIVERSAL SOCIAL PROGRAMS IN THE UNITED STATES?: A Historical Institutionalist Comparison with Canada:

Much has been written about “American exceptionalism” in social policy, but one aspect has received relatively little attention thus far: the absence of universal public social programs where entitlements to benefits and services are derived from citizenship or residency. This absence is especially striking because other liberal welfare regimes such as Canada and the United Kingdom have long developed such programs. Focusing on policy design and using Canada as a contrasting case, this article explains why there are no universal social programs in the United States, a country where the dichotomy between social assistance and social insurance dominates. The empirical analysis focuses on three policy areas: health, pensions, and family benefits. Stressing the impact of institutional factors on policy design, the article adopts a historical institutionalist approach and shows that the explanation for the absence of universal social programs varies from one policy area to the next.

Paths to (de)centralization: Changing territorial dynamics of social policy in the People’s Republic of China and the United States

Drawing on the existing welfare state literature, this article offers a comparative analytical framework to account for the territorial dynamics of social policy in the United States and the People’s Republic of China, two countries that are most dissimilar in terms of political regime but that may exhibit similar territorial patterns of social policy fragmentation. A promising way to explore such patterns, we argue, is to analyze how changes in the architecture of major governing institutions affect the territorial dimension of social policy. In the United States, state governments and a territorially-organized federal legislature have increasingly accommodated national political parties. These two parties have turned the politics of social policy into a debate over the boundaries of national or state governance of social policy, resulting in multi-level governance frameworks. In the People’s Republic of China, the partisan dimension is absent, but strong economic pressures on the central bureaucracy have made devolution a functional imperative and have given local governments increasing leverage when bargaining with the center.

A New “War on Poverty”? A Story of Policy Success, Frustration and Restraint

Obama’s reticence to speak directly about poverty continued into his presidency, with his language about the economy emphasizing the plight of the middle class rather than the poor. Nevertheless, the Obama era did see some policy efforts, such as the expansion of the Supplementary Nutrition Assistance Program (more commonly referred to as Food Stamps), which did specifically aim to help those who were the least well-off. The purpose of this chapter is to look at the scope and ambition of the Obama administration’s policy efforts to address the problems of those still living in poverty in the USA, even if this was not done with the same rhetorical flourish as when the president focused on inequality.