This special issue of the Journal of Health Politics, Policy and Law on the role of policy analysis in the development and implementation of the Affordable Care Act (ACA) took shape during the spring and summer of 2017, while Congress was enmeshed in an attempt to repeal the ACA and, perhaps, replace it with an alternative health plan. Republicans struggled to make good on their campaign promise—reiterated across four federal election cycles—to undo the ACA, despite the GOP's control of the House, Senate, and presidency. In March, the House's initial attempt at repeal failed, delaying the process and galvanizing a growing opposition. The House narrowly passed a repeal-and-replace bill in May, just as our special issue conference took place, and the Senate took up the bill in early June, with plans to pass its own version by Independence Day. That effort, much delayed, ended in a dramatic failure at the end of July. A subsequent effort in early September also collapsed. As I write, a bipartisan bill aimed at stabilizing health insurance marketplaces is being developed, while the administration is taking steps to discourage enrollment.
As this drama has played out, commentators on both the left and the right have highlighted aspects of the repeal process that implicate themes discussed in this special issue. One strand of this commentary has lamented the limited scope of policy ideas informing repeal. Paul Waldman (2017) noted in the Week that Republicans “never cared all that much about the substance” of health care reform and lacked the stomach to do the hard work of crafting a bill that would balance ideological aspirations, public preferences, and administrative realities. Historian Guian McKee (2017), writing in the Washington Post, argued that Republicans “are stuck with inferior policy solutions” because Democrats have stolen their best ideas, such as using regulatory mandates to expand coverage. Another strand has emphasized the distributive impacts of repeal on lower-income Americans and the costs that repeal would impose on working-class voters within the Republican base. This strand relied heavily on policy analytic projections of the effects of eliminating the law's subsidies and regulations. A further debate has arisen around the role of the Congressional Budget Office (CBO). CBO's estimates (or lack of estimates) on the consequences of alternative repeal bills drew considerable attention, even as some Republicans argued that CBO has too much institutional power and that its analyses were flawed.
The articles in this volume examine whether policy analysis mattered in the lead-up to the ACA and assess how key features of the health care policy arena, including technical complexity and high stakes, affected the uses of policy analysis. They examine whether changes in the external climate, especially polarization and partisanship, have affected the use of policy analysis in the policy-making process. These themes resonate equally in the repeal-and-replace debate.
Mark A. Peterson's article provides a conceptual framework for considering both the production and consumption of research evidence in the policy process. He delineates the broad array of actors that produce research evidence and communicate it to policy actors, encompassing those who develop long-standing trusted relationships with policy makers as well as those who focus their efforts on pushing new evidence in response to a specific policy opportunity. Peterson then turns to the acquisition and use of that evidence, emphasizing the role of institutionalized analytic capacity. Notably, his analysis points out the pivotal role of the CBO as a producer and consumer of research evidence in the context of the ACA. That pivotal role—and the continued ability of CBO to credibly consider and disseminate research evidence even within a highly skeptical political atmosphere—was clearly evident once again in the repeal-and-replace debate.
The question of capacity for the production and consumption of research evidence surfaces as well in David K. Jones and Christopher J. Louis's study of the use of evidence in state policy making. Jones and Louis compare the use of policy analysis in the development of policies affecting infant mortality and those affecting state-run health insurance exchanges. In addition to noting the availability of internal capacity for assessing research evidence, they point out that research evidence is more likely to come into play in less highly politicized environments. But evidence, of sorts, does matter even when issues are highly politicized. Jones and Louis point to pathways, such as the use of expert consultants, that bring evidence to the attention of policy makers in these circumstances.
Jones and Louis argue that policy analysis is more likely to influence decisions made by the executive branch than the legislative branch. Steven Sheingold and colleagues' study of social risk factor adjustment in Medicare pay-for-performance programs casts some doubt on that conclusion. In their case study of how policy analysis did and did not affect policy making within the executive branch, Sheingold et al. describe the process that generated the call for policy analysis and elucidate the strengths and weaknesses of the analysis conducted. Ultimately, they note, policy analysis entered the decision-making process as just one of many considerations. In an ironic twist, just as the executive branch chose to delay taking action on social risk factor adjustment, the legislative branch moved forward with such action, employing a methodology that was not favored by the empirical analysis. In the repeal-and-replace context, the reverse pattern is taking place, with the executive branch seeking to achieve through administrative action effects that the legislative branch could not.
Carolyn Hughes Tuohy's article turns from the use of research evidence per se to the incorporation of empirical claims in policy narratives in both historical and cross-national perspectives. Tuohy explores the narratives that underlie health care reforms in the United States, Canada, and Europe, cautioning that the fragmented narrative of the ACA, building on an aggregation of individual stories about vulnerable people left out of the existing insurance system rather than on traditional narratives about either social solidarity or self-help through contributory social insurance, could easily be undercut by an epic narrative couched in terms of resistance to government tyranny. The battle between these two narrative styles has continued into the repeal-and-replace era, with the tale of Jimmy Kimmel's son dueling against the lure of the free market.
In his examination of why the ACA failed to include strong measures to reduce the personal cost of health care for the already insured, such as price controls, Joseph White also considers the stories and ideologies that lie behind research analyses. He concludes that ideas of prestigious experts (such as economists) that match decision makers' theoretical predilections may triumph over better-tested measures that conflict with their preferences. The big exception to this pattern, White argues, is in the area of federal budget scorekeeping; CBO bases its estimates on direct evidence and has generally been unwilling to credit novel proposals with savings on the basis of theoretical models. This pattern of what kinds of claims gain political influence (but not favorable CBO scores) recurred often in the repeal-and-replace debate, with arguments based in theory but not on direct evidence about the cost-savings power of sales of insurance across state lines or less regulated insurance market competition.
Jonathan Oberlander and Steven B. Spivack offer a different take on the cost containment issue in their evaluation of the odd case of the Independent Payment Advisory Board (IPAB). As they demonstrate, the IPAB offers a case study in both the substantive and political limits of technocracy. From a substantive perspective, despite the fond hopes of its proponents, the IPAB was never expected to generate much in the way of Medicare savings. In practice, the slowdown in Medicare cost growth in the period since the ACA passed meant that its provisions were never triggered. From a political perspective, the specter of the IPAB harnessed the fears of both conservative and liberal lawmakers. Some saw it as an instrument of rationing; others saw it as a technocratic abrogation of the prerogatives of elected legislators. While the IPAB itself did not figure much in the repeal-and-replace debate, skepticism about unelected commissions and boards, and about the evidence that they bring to bear, remained front and center in the critiques of CBO during that later debate.
Elizabeth Rigby and Kimberly J. Morgan offer a more granular perspective on the actors producing policy analysis in their study of the use of advocacy and research in the effort to save the ACA between January and May of 2017. Think tanks, advocacy organizations, and research centers, rather than academic scholars, produced the bulk of the analyses used by advocates and lobbyists in these efforts. Moreover, most of the policy analyses produced by this nonacademic research community did not cite academic papers to support the research. Rigby and Morgan raise the question of whether the lack of academic engagement should even be seen as problematic. Perhaps, in the context of Peterson's army of evidence producers, academics are simply not needed in the short-term policy analysis game.
Finally, my commentary concludes the special issue by considering how differences in institutional culture explain the relationship between academics and government policy analysts. I suggest that, as in other situations of diverging cultures, embedding academics in government can build trust and increase the flow of research-based ideas into policy. The fact that numerous academics served in the Obama administration may explain why, in contrast to some prior experiences, the general consensus of the authors of the articles in this special issue is that policy analysis, for better or worse, did play a substantial role in the development, implementation, and defense of the ACA.
Acknowledgments
The papers in this special issue were presented on May 2, 2017, at a New York University Robert F. Wagner Graduate School of Public Service conference that was cosponsored by JHPPL and Wagner. During that conference, Larry Brown, Larry Casalino, Jonathan Engel, Jeanne Lambrew, Miriam Laugesen, Dahlia Remler, Victor Rodwin, and Michael Sparer offered insightful comments on the papers and Ted Marmor provided valuable remarks on the role of policy analysis in the design and implementation of the Affordable Care Act and other health legislation. We thank all of the commenters for their participation.
