Eric M. Patashnik

After the Public Interest Prevails: The Political Sustainability of Policy Reform

The prevailing political science wisdom is that narrow interests regularly triumph over the general public. Yet the stunning passage of broad-based policy reforms in the face of intense clientele opposition suggests that the U.S. political system has a greater capacity to serve diffuse interests than has often been thought. Some of the most provocative policy-oriented political-science research during the 1980s and 1990s examined how these surprising reform victories occurred. Unfortunately, general-interest reforms do not always stick; reforms may be corrupted or reversed after their enactment. The long-term sustainability of any given policy reform hinges on the successful reworking of political institutions and on the generation of positive policy-feedback effects, especially the empowerment of social groups with a stake in the reform&s maintenance. This paper explores the postenactment dynamics of three canonical instances of general-interest reform legislation: tax reform, agricultural subsidy reform, and airline deregulation. Only in the airline-deregulation case has the self-reinforcing dynamic required for political sustainability been unmistakably evident. For analysts and advocates of general-interest reform measures alike, the clear lesson is to attend far more closely to what happens after reforms become law.

The Struggle to Remake Politics: Liberal Reform and the Limits of Policy Feedback in the Contemporary American State.

President Barack Obamas two signature first-term legislative victories—the Affordable Care Act and the Dodd-Frank Act—are the law of the land, but the political battle over their entrenchment continues. The question now is whether these landmark reforms will be consolidated and create a new politics going forward. We develop an argument about the limits of policy feedback to illuminate the obstacles to durable liberal reform in the contemporary American state. We argue that political scientists have paid insufficient attention to the fragility of inherited policy commitments, and that the capacity of reforms to remake politics is contingent, conditional, and contested. Feedbacks are shaped not only by the internal attributes of policies, but also by the interaction between policy-specific characteristics, the strategic goals of officeholders and clientele groups, and the political forces arising from a contentious and uncertain political environment.

Between Welfare Medicine and Mainstream Entitlement: Medicaid at the Political Crossroads

As the new century begins, the Medicaid program is arguably at a political crossroads. Over the 1980s and 1990s, policy makers enacted major expansions in Medicaid coverage, offering significant new health benefits to poor women and children and other constituencies. In elite rhetoric and political framing, Medicaid was increasingly cast as a broad-based social welfare entitlement of value to all Americans, including middle-class citizens. Some health care advocates began viewing Medicaid expansions as a potential path to achieving universal coverage in the United States. Yet Medicaid remains a means-tested program that has been repeatedly threatened with policy retrenchment. In this essay, we scrutinize Medicaids current status and future possibilities from a historical-institutional perspective by tracing its complex evolution since its enactment in the Social Security Amendments of 1965. Our core claim is that decisions made at the time of Medicaids original adoption have fundamentally set the matrix for struggles over the programs unfolding development. We demonstrate that key ambiguities embedded in the 1965 act created largely unintended opportunities for policy entrepreneurs to broaden Medicaids scale and scope as well as foreseeable vulnerabilities that must be overcome if Medicaid is to realize its full potential.

The Public Wants Information, Not Board Mandates, From Comparative Effectiveness Research

We conducted two national surveys of public opinion about comparative effectiveness research and the integration of findings from the research into clinical practice. The first survey found broad support for using research results to provide information, but less support for using them to allocate government resources or mandate treatment decisions. In addition, the public is willing to consider the use of financial incentives to encourage patients to choose cheaper treatments, if research demonstrates that they work as well as more expensive ones. The second survey found that support for comparative effectiveness research dropped in response to general debates about its consequences but that arguments against the research could be effectively countered by specific, targeted rebuttals.

A National Survey Reveals Public Skepticism About Research-Based Treatment Guidelines

Using research to develop treatment guidelines is one way to lower medical costs and improve care. However, findings from a national survey show that the public is skeptical about this approach. Specifically, the public finds arguments against establishing research-based treatment guidelines more convincing than arguments in favor of it. Our findings suggest that for evidence-based treatment guidelines to win public acceptance, the public needs to be reassured that guidelines would not lead to the limiting of access to beneficial care.

Universalism within Targeting: Nursing Home Care, the Middle Class, and the Politics of the Medicaid Program

In contrast to “targeting within universalism,” in which extra benefits are directed to low‐income groups within the context of a universal policy design, the reliance of mainstream elderly on means‐tested Medicaid benefits represents the inverse pattern of “universalism within targeting.” During moments of intense debate, policy elites have strategically reframed Medicaid as a broad‐based social entitlement, yet many politicians remain ambivalent about using a program originally intended for the poor to protect the middle class. The analysis suggests that universalism and targeting are best seen not as fixed, technical features of program structures but rather, as the political raw materials with which politicians contest the multiple and conflicting purposes of the American welfare state.

The Politicization of Evidence-Based Medicine: The Limits of Pragmatic Problem Solving in an Era of Polarization

THE CALIFORNIA Journal of Politics & Policy Volume 3, Issue 4 The Politicization of Evidence-Based Medicine: The Limits of Pragmatic Problem Solving in an Era of Polarization Alan S. Gerber Yale University Eric M. Patashnik University of Virginia Abstract A key test of a political system is its capacity to solve important societal problems. Few policy areas in the U.S. are more problem-ridden than health care. Medical care is expensive and wasteful, and the quality often falls short of best practice. One idea to improve health care is to eliminate gaps in the medical evidence base through “comparative effectiveness research” (CER). By identifying what treatments, tests, and technologies work best, CER could help doctors, patients, and payers make better decisions and help reduce wasteful spending. CER was a technocratic, third- tier issue familiar mainly to policy experts based in universities, foundations, and think tanks, but hardly anyone else. This paper traces how this obscure policy ini- tiative got caught up in the wider ideological struggle over national health reform . Keywords: health care reform, The Affordable Health Care Act, comparative ef- fectiveness research, evidence-based medicine Copyright

Introduction: Health Reform after the 2016 Election

When Donald Trump was elected president in 2016, along with Republican majorities in both the House and the Senate, the future of US health policy was immediately thrown into doubt. Trump had campaigned against the Affordable Care Act (ACA), promising to replace it with “something terrific” (Sanger-Katz 2017). Trump had also pledged that “I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid” (Brewster 2017). It was impossible to predict on election night what health reform proposals Trump would actually support once he was faced with the unfamiliar reality of having to govern. Would he embrace the welfare state retrenchment proposals of conservatives like House Speaker Paul Ryan (R-WI)? Or would he seek to carve out a bipartisan middle ground? During his first year in office, it became clear that Trump would govern from the right on domestic policy and that he would almost certainly sign any health reform bill that landed on his desk. The question then became whether the GOP’s seven-year drive to repeal the ACA—the boldest effort to dismantle a major social program in modern US history—would finally succeed. It very nearly did. The House passed a sweeping ACA repeal bill (which also contained a massive cut to Medicaid), but similar legislation fell two votes short in the Senate when Republicans John McCain, Lisa Murkowski, and Susan Collins joined all Democrats to vote against the measure. Still, the battle over health care reform continued. The individual mandate at the heart of the bill was eliminated as part of tax reform, and the Trump administration used its executive authority to undermine the law’s implementation.

After Defeat: Conservative Postenactment Opposition to the ACA in Historical-Institutional Perspective

Since the enactment of the Affordable Care Act (ACA) in 2010, conservatives have sought to undermine the law’s entrenchment. While they have failed in their ambitious quest to repeal the ACA, opponents have succeeded in overturning one major provision (the individual mandate penalty), narrowing the law’s reach, complicating its implementation, and fomenting doubts about its political sustainability. This essay places the postenactment battle over the ACA in historical-institutional perspective by juxtaposing the strategic choices that conservatives have made to limit the role of the federal government in the core social welfare areas of pensions and health since the New Deal. Our central argument is that conservatives’ varying strategies of postenactment opposition, resistance, and accommodation for Social Security, Medicare, Medicaid, and the ACA have been shaped by shifts in conservative ideology, changes in control of institutional resources, and the nature of policy feedback. Attention to these contextual factors helps explain why ACA opponents viewed the law as a threat despite its moderate policy design, why opposition did not subside after the law’s enactment, and how conservatives managed to keep the conflict going across multiple election cycles.

Congress and the Federal Reserve: Independence and Accountability

In his last press conference as chairman of the Federal Reserve’s Board of Governors in 2013, Ben Bernanke was asked what advice he would offer Janet Yellen, the incoming chair, for dealing with Congress. Bernanke kept it simple: “Congress is our boss” (Federal Reserve 2013, 29). The Federal Reserve’s (or Fed’s) relationship with Congress is hardly that straightforward. Indeed, Bernanke immediately added: “It is important that we maintain our policy independence in order to be able to make decisions without short term political interference.” Bernanke’s advice and admonition highlight the inevitable tension for Congress between insulating monetary policy from political pressure and holding the Fed accountable for its policy decisions. The trade off between independence and democratic accountability is most apparent in the wake of financial and economic crises with interest rates at zero and central banks compelled to break the glass, tapping unconventional tools to ease policy further. Indeed, the recent global financial crisis reveals the limits of central bank independence. In the United States, Europe, and Japan, politicians have renewed their focus on central banks – replacing governors, revamping lending powers, and demanding greater accountability. Heightened oversight of monetary policy contrasts sharply with studies of central bank autonomy: Politicians are said to prefer independent central banks because more independent monetary authorities aim to deliver lower and more stable inflation (Alesina and Summers 1993). Committing in advance to central bank autonomy in theory prevents politicians from interfering with monetary policy to ease conditions for electoral gain.