5 PLAN OF THE BOOK AND CASE STUDY INTRODUCTION | Public-policy textbook

PLAN OF THE BOOK AND CASE STUDY INTRODUCTION

Public Policy: Origins, Practice, and Analysis, includes seven chapters that introduce students to public policy and the policy making process. Unlike textbooks that include multiple case studies in each chapter, this text uses one case study that runs throughout the book and does so with the intent of giving sufficient detail to a single case familiar to students: the Affordable Care Act of 2010, otherwise known as Obamacare. This case provides an ideal overview of the policy process, and it is used here to explicate each chapter’s respective focus. The case study begins with the history of health policy in the U.S. dating back to the eighteenth century and concludes with an analysis of the status quo, along with three alternatives.

The healthcare debate, as we examine in chapter two, is rooted in American political culture’s relationship with free market capitalism, tied with a lack of faith in a centralized government’s ability to carry out policies efficiently. Nevertheless, presidents since Theodore Roosevelt have pushed for healthcare reform. The story of health care’s origins follows the themes discussed in chapter two and include the development of American government institutions and the history of U.S. public policy growth.After considering the historical evolution of American healthcare, we dive directly into the Affordable Care Act (ACA).

Chapter three considers the important actors in crafting and passing legislation, with a special focus on shifts within the Senate that allowed for the passing of the ACA. The Senate provides a major hurdle in the legislative process, since it often requires a filibuster proof majority to enact controversial legislation. President Obama entered office with a fifty-nine-seat Senate majority comprising fifty-seven Democrats and two independents who caucused with the Democratic Party. Senator Arlen Spector (R-PA) switched  parties in April 2009, thereby giving Democrats a supermajority. Unfortunately for President Obama, Senator Ted Kennedy (D-MA) died in August the same year, thus putting the legislation in jeopardy. Nevertheless, the legislation ultimately passed.

Figure 1.3: Barack Obama signing the Patient Protection and Affordable Care Act.Source: Wikimedia Commons Attribution: Pete Souza License: Public Domain 

Chapter four discusses in detail the legislation’s passage, giving emphasis to agenda setting. A policy’s success depends largely on how it is framed. Democrats and Republicans alike used the media to promote (Democrats) or denounce (Republicans) the policy. Democrats framed the issue as a means of covering more individuals and of allowing individuals already covered more protections, e.g., preventing insurers from denying coverage to consumers with preexisting conditions. Republicans, on the other hand, executed a campaign that dominated the media’s attention, most notably with claims of “death panels” and the lack, or loss, of consumer choice.

Chapter five examines the design and formulation of public policy. President Obama campaigned on a public health insurance option, but its elimination was a concession necessary for getting support from a majority of Congressmembers. Furthermore, President Obama established a coalition of groups and individuals (doctors, insurance companies, pharmaceutical companies, labor unions, and elected officials) to design a policy that would reflect a set of shared principles. The result was a policy that allowed states greater influence on policy implementation, thus addressing the barriers mentioned earlier regarding America’s distrust of federal government intervention in state policies.  

Chapter six considers the implementation of public policy. The partisan backdrop made policy implementation of the ACA challenging, especially its provision requiring state support. The law mandated Medicaid expansion, a provision that relied on state action, which was challenged in court. The Supreme Court ruled the mandate violated the Tenth Amendment, a major setback for implementation. As of 2020, fourteen states have opted out of Medicaid expansion. As with intergovernmental challenges, the policy also relied on coordination between actors outside the political realm, e.g., private insurers, employers, and consumers.

Lastly, successful implementation rested on public support. The public disapproved of the policy until 2017, though many favored specific provisions in the law, including protecting coverage of pregnant women and individuals with pre-existing conditions, prohibiting insurers from charging sick people more, and allowing young people to remain on their parents’ insurance until age twenty six.The case study concludes with an analysis of the Affordable Care Act, beginning with the problems Obamacare was unable to solve—making insurance affordable and expanding Medicaid. Various proposals have been offered as a substitute, which we analyze in detail. Each alternative is systematically assessed using a set of established criteria to determine the preferred policy. Taken together, the six sections of the case study will give students an in-depth look at a policy that remains contentious and will remain a salient issue for the foreseeable future.