Abstract:The 2010 Patient Protection and Affordable Care Act (ACA) passed through Congress on partisan lines and with only lukewarm public support. The Obama administration and Congressional Democrats, though, had reason to expect that the ACA's political fortunes would substantially improve as the acrimonious debate over its enactment faded and millions of Americans came to receive significant benefits from health care reform. But 5 years after its passage, the ACA's political foundations remain shaky. We suggest that one reason for the ACA's unsettled fate is the role of policy feedbacks that undermine public support for and opponents' acceptance of the program. The ACA experience highlights how policy feedbacks can vary widely in their political impact, and suggests that some policies are in fact self-undermining. We also emphasize the crucial role of partisan polarization as a mediating factor in shaping policy feedbacks.

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Enactment of the Patient Protection and Affordable Care Act (ACA) created a dilemma for Republican policy makers at the state level. States could maximize control over decision making and avoid federal intervention by establishing their own health insurance exchanges. Yet GOP leaders feared that creating exchanges would entrench a law they intensely opposed and undermine legal challenges to the ACA. Republicans' calculations were further complicated by uncertainty over the Supreme Court's ruling on the ACA's constitutionality and the outcome of the November 2012 elections. In the first year of operation, only seventeen states and the District of Columbia chose to design and implement their own exchanges; another six partnered with the federal government, and twenty-seven states ceded control to Washington. Out of thirty states with Republican governors in 2013, only four launched their own exchange. Why did many Republican-led states that initially appeared open to establishing exchanges ultimately reverse course? Drawing on interviews with state policy makers and secondary data, we trace the evolution of Republican responses to the exchange dilemma during 2010-13. We explore how exchanges became controversial and explain why so few Republican-led states opted for their own exchange, focusing on the intensifying resistance to Obamacare amid a rightward shift in state politics, partisan polarization, and uncertainty over the ACA's fate.

Health reformers have an established record of losing. Going into 2009, there were plenty of reasons to believe that they would fail again. A polarized political environment, soaring budget deficits, and myriad other obstacles stood in the way. Yet the Obama administration and congressional Democrats defied the odds. Democrats won the 2009-10 health reform battle by successfully applying lessons learned from past failures, including the importance of neutralizing interest-group opposition. The result is historic legislation that, given the constraints imposed by both the U.S. political and health systems, is probably as good as it gets.

Controlling the costs of medical care has long been an elusive goal in U.S. health policy. This article examines the options for health care cost control under the Obama administration. The authors argue that the administration's approach to health reform offers some potential for cost control but also embraces many strategies that are not likely to be successful. Lessons the United States can learn from other countries' experiences in constraining medical care spending are then explored.