The enactment of the Patient Protection and Affordable Care Act (ACA) in 2010 was full of surprising puzzles. First, how does a market-based reform intended to create competition among health plans for health care consumers get labeled as a liberal socialist reform? Second, given that the ACA passed with no Republican votes, is it true that Democrats did not compromise and that Republican proposals were not included in the ACA? Third, with employer-based health insurance covering the majority of Americans, why were major US employers so conspicuously silent on the most significant health care legislation since the passage of Medicare and Medicaid? Fourth, given that Republican-led states were so adamantly against the federal ACA mandate to expand Medicaid, because of concerns about federal “coercion” over state discretion, why have the vast majority of Republican-led states abdicated their right to establish a state-controlled health insurance marketplace in favor of a federally controlled marketplace? Fifth, does the ACA's creation of the Patient-Centered Outcomes Research Institute (PCORI) provide legitimate hope that health care decisions will be based on rational comparative-effectiveness research? And, finally, how should state health insurance marketplaces be structured and governed to fulfill their promise of adequate, affordable, and meaningful consumer choice? All these questions and more are addressed in this issue.

Jill Quadagno's article, “Right-Wing Conspiracy? Socialist Plot?,” provides a detailed political history of the most controversial component of the ACA — the individual mandate — from its origins as a Republican policy idea starting in 1993 to the Democratically led passage of Obamacare in 2010. She shows how the basic components of this policy design have remained intact, while partisan positioning around an unchanging design have shifted over time. This long-term view of partisan support for specific policy designs is especially helpful alongside “Party Politics and Enactment of ‘Obamacare,’ ” by Elizabeth Rigby, Jennifer Hayes Clark, and Stacey Pelika. In this article, the authors empirically examine minority-party claims that Democrats did not give serious consideration to Republican ideas and did not incorporate Republican proposals into the final bill. Rigby, Clark, and Pelika find that although Republican-backed proposals were included on the policy agenda, they were less frequently found in the final legislation — instead, both the agenda and final legislation were dominated by Democratic policy proposals. Of course, one might expect this result in a Democratically controlled Congress. However, what one would not expect is what Quadagno's time frame makes clear — that a decade-long Republican idea not only successfully passed a Democratic Congress but became a central component of the ACA.

It is almost unheard of that powerful interest groups would remain silent on a congressional bill that stands to have considerable impact on their interests, yet large US employers have done just that. Marc Smyrl's article, “Beyond Interests and Institutions: US Health Policy Reform and the Surprising Silence of Big Business,” examines this puzzle and finds that a historically determined ideology of US firms goes a long way in explaining their silence. Smyrl argues that the establishment of employer-based health insurance in the mid-twentieth century indoctrinated US business in the principles of private welfare provision along with opposition to expanded government control. While the institution of employer-based health insurance was once complementary with controlled and minimal government, they are now, according to Smyrl, at odds. Because employer-provided health insurance is now possible only at the cost of ever-increasing government subsidy and regulation, business is paralyzed by this clash of ideas. Smyrl documents how major employers were unable to take a coherent and unified stand for or against the ACA, and as a result, they failed either to oppose it successfully or to secure modifications.

The fourth ACA puzzle looks to the American states and considers a central contradiction between Republican ideology and action. David K. Jones, Katharine W. V. Bradley, and Jonathan Oberlander ask, “Why did many Republican-led states that initially appeared open to establishing exchanges ultimately reverse course?” Out of thirty states with Republican governors in 2013, only four are launching their own exchanges. Drawing on interviews with state policy makers and secondary data, they trace the evolution of Republican responses to the exchange dilemma during the implementation stage of 2010–13. They identify three main factors to explain why so few Republican-led states opted for their own marketplace: intensifying resistance to Obamacare amid a rightward shift in state politics, partisan polarization, and uncertainty over the ACA's fate.

Next, we turn to the hope that specific policy mechanisms in the ACA might reduce health care costs and improve the quality of care provided. Of course, this is the search for the holy grail in health care reform, and the most prominent holy grail in the ACA is comparative effectiveness research, or CER. Corinna Sorenson, Michael Gusmano, and Adam Oliver examine the political history of past efforts to use CER over the last forty years. They find concerns that CER was being used to ration services under the guise of science presented the major stumbling blocks to widespread use in the past. Given the debate that emerged around PCORI during its passage in 2009–10, such concerns will likely continue to be the major barrier. They argue that for CER to be effective, significant improvement is needed in three areas: adopting realistic aims about its impact, demonstrating the impact of PCORI and communicating the benefits of CER, and maintaining strong political and stakeholder support.

Focusing on that last issue — the need to maintain strong political and stakeholder support — Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor M. Dowling argue that public opinion is highly influenced by provider support for CER. To test this contention, they conducted two national surveys to explore the public's confidence in doctors compared with other groups. They found that doctors are viewed as harder working, more trustworthy, and more caring than other professionals. Moreover, through the use of survey experiments, they demonstrate that provider support (or opposition) for CER has a greater influence on aggregate public opinion than do cues from political actors, including congressional Democrats, Republicans, and a bipartisan commission. Their findings suggest that one crucial component of CER's success will be the ability of PCORI staff and agency directors to work with and garner the support of provider groups.

Finally, another holy grail of American health care reform, at least since the 1980s, is the effort to bolster consumer choice in a competitive health care marketplace. Here, too, embedded in the ACA, is hope that consumer choice will reduce health care costs and improve the quality of care provided. Pamela Nadash and Rosemarie Day consider consumer choice under the newly constructed state health insurance marketplaces, asking “Can we make it work?” They draw on previous research in order to determine how best to structure and govern state marketplaces so that the hope for a consumer-choice holy grail can become a reality.

We end this issue with our biannual Point-Counterpoint on whether whole genome sequencing should be covered under the ACA. Because the section's editor, Harold Pollack, has a separate introduction to this pair of articles, I end my musings and summaries here so you can get on to the real meat of these puzzles and hopes. Enjoy!

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