1Since the 1980s, American health insurance policy has undergone significant transformations. It has likewise experienced a kind of re-politicization, where questions of principle concerning the role of the state in providing and guaranteeing health insurance coverage for everyone were once again brought to the table. These past few years, the topic of health insurance has been the focus of exceptionally intense public debate and has crystallized opposing party political positions. Four years after the Patient Protection and Affordable Care Act (hereafter referred to as the ACA), also known as Obamacare, was passed, the reform remains highly controversial, both its basis and implementation being challenged. The government shutdown orchestrated by congressional Republicans in October 2013, which sought to deprive the Obama administration of the resources it needed to implement the ACA, was just one more visible example of the persistent antagonism between Democrats and Republicans. The politicization of healthcare issues is nothing new: since the 1920s, when the first proposals designed to create a national healthcare system emerged, every new initiative has encountered strong social opposition.  Unable to implement radical, structural reform, public policy has instead developed incrementally,  shaping the contours of a costly and fragmented system, predominantly private and based on employer-sponsored health insurance (occupational insurance covered 50 per cent of the population in 2011),  in which the federal state acts as an insurer of last resort for those segments of the population who do not have access to the private health insurance market. This includes retirees, covered through the Medicare programme, and low-income individuals and families, covered through the Medicaid programme; together, these two policies cover about 30 per cent of the total population.
2Although the heated nature of healthcare issues in the United States is not a recent phenomenon, what does appear to be new, however, is the partisan structure of political debate on the issue, as illustrated by the passing of the ACA, reminiscent more of an electoral competition between Republicans and Democrats than a traditional situation of interest group politics. In fact, the majority of the social and economic groups in the healthcare sector were not opposed to the reform:  in a context where healthcare costs account for more than 16 per cent of the United States’ GDP, and where 45 million Americans were uninsured, employers, insurers, medical professionals and hospital lobbyists – traditionally opposed to any intervention by the federal government – all supported reform, more or less actively and more or less publicly. If we add to this picture union movements, patient associations, and pensioners’ associations, a large base for support becomes visible. While a targeted reading of interest groups does not truly paint the picture of the conflict surrounding Obamacare, analyzing the programme’s substance does not really provide us with a satisfactory interpretation either. Obamacare is a centrist reform that extends access to healthcare by relying on the private insurance market and in no way constitutes the “socialization of the healthcare system”, as conservative rhetoric often proclaimed. Its provisions are some distance from the options traditionally supported by American liberals. The very concept of an individual mandate, a core element of the reform, had been supported in the 1990s in conservative circles.  A very similar reform had been tentatively implemented in Massachusetts in 2006 by Republican governor and 2012 presidential candidate Mitt Romney.  Beyond the political instruments themselves, which seemed likely to garner consensus, the issues that emerged during the ACA battle stemmed more from party politics than anything else: Republicans had simply decided that it was in their interest to cause a Democratic reform to fail. The recent debates on healthcare issues mark the reappropriation of the political cleavage between liberal and conservative values by the Democratic and Republican parties; through their opposition, they also symbolize the intensity of the party political games that characterize federal politics today.
3In the American context, the role played by partisanship is perhaps not so immediately obvious. Political parties and the partisan discipline of the political class have traditionally been weaker than in European parliamentary regimes. Nevertheless, this situation has changed since the 1980s, and the revival of partisan cleavages can be seen today. Termed “partisan polarization”, this phenomenon is now widely recognized by political researchers.  This expression designates more contentious exchanges between parties and a greater partisan split in American political life. In Congress, the main institution of the American political system, debates between legislators are generally polarized around the question of state intervention in economic affairs; today this polarization affects a growing number of political issues too.  In addition to the opposition between the two main parties, how policies are developed has changed as well. Policies now go through a process of partisan contextualization that provides a framework for each step of the production and implementation of laws, and which has given rise to new practices termed “unorthodox lawmaking” by Barbara Sinclair.  This expression designates legislative procedures that accord a lesser role to bipartisan debate and negotiation in standing committees, which had been one of the main characteristics of congressional government during the twentieth century.  The realization that partisan logic in Congress and in federal politics more generally was gaining power, and the subsequent rise of polarization studies, have been relatively slow in coming. The first works to highlight the strengthening of political parties appeared at the beginning of the 1980s  and were situated far from the mainstream literature, where studies drew on a distributive and pluralist reading of the behaviour of legislative actors. In the 1990s, the voices emphasizing the strengthening of political parties grew more numerous and they began to insist on the importance of paying attention to the influence of these structures in order to understand Congress’s political agenda and how legislative work was organized.  Ultimately, it was the changeover that occurred in 1994, marking the arrival of the Republicans in power, led by the speaker of the house Newt Gingrich – whose “strong party” strategy significantly embittered partisan conflicts – that allowed polarization studies to truly take off, ultimately becoming a standard research topic in American political science.  From an analytical point of view, this article adopts this perspective and raises the question of the consequences of partisan polarization on the development of American healthcare policies. I am interested in the relationship between the formulation and reform of public policy, and the political context and battles that surround it. This subject has not often been addressed in French scholarly literature,  although it is becoming a frequently studied topic in Anglo-Saxon research on the evolution of the welfare state in Europe.  In the context of American academia, the question of the link between politics and policy is raised more frequently.  In the realm of social policy, studies within the neo-institutional paradigm, such as the work done by Jacob Hacker, Paul Pierson, Margaret Weir and Carolyn Tuohy,  have considered the weight of institutions and actors in the elaboration of policies by asking this very question. Below, I shall analyze the evolution of the process of policy-making alongside the evolution of power struggles between political actors. This article poses the following question: what is the impact of partisan polarization on the content of healthcare policy?
4In terms of methodology, the arguments presented here are based on qualitative observation, comprising 100 semi-structured face-to-face interviews conducted between 2008 and 2010 with different actors involved in recent healthcare system reforms, including elected members of Congress, legislative advisors, former White House or Department of Health and Human Services advisors, and lobbyists (for medical professionals, hospitals, health insurance companies and the pharmaceutical industry). Three sets of interviews were conducted over three months each in Washington: during the 2008 summer electoral campaign; while the Obamacare reform was in development in the spring of 2009; and after the ACA was passed in the spring of 2010. These successive periods of fieldwork allowed me to meet certain actors involved in the reform multiple times, at different stages in the reform’s development, and to record their accounts during these different phases. Although the interviews constitute the main source used in this article, I also conducted a press review, and consulted various legislative sources (legislative debates, reports published by the Congressional Research Service, and reports provided by standing committees).
5After reviewing the decisive factors in the bipolarization of the American political party system and how this manifested itself, the analyses that follow argue that the strengthening of partisan logic facilitated both the passing of conservative reforms in the 1990s and the adoption of the ACA in 2010, in a sector frequently believed to be impossible to reform. 
Partisan polarization and the resurgence of American political parties
6In the United States, political parties have long been described as somewhat eclectic groups that are rarely programmatic and have limited influence on both locally and federally elected officials. This view became widespread in the 1950s and 1960s, when political science regularly referred to a crisis of party politics. Today, this situation has evolved. Several changes have transformed the framework of electoral competition and helped to align elected officials more closely along party lines. These factors are relatively well addressed in the relevant literature.  They stem from increased coherence within parties and a more partisan method for selecting political candidates.
Increased party coherence and a more partisan method for selecting political candidates
7American political parties have traditionally been seen as flexible organizations, bringing together diverse actors, both geographically and ideologically. During the twentieth century, the cleavage within the Democratic Party between Southern elected officials, who were typically more conservative, and Northern elected officials, who were typically more liberal, was emblematic of the factions that existed within parties. Parties did not support a single political platform, but rather appeared to be coalitions formed by very different political players.  Acknowledged until the 1980s, this political situation is much less prevalent today. American elected officials appear more similar across the board. The first reason for this change stems from a political realignment that transformed the electoral geography of both parties: while in the 1960s constituencies in the South of the US were predominantly Democratic, they are now largely Republican.  This realignment meant that the Democrats lost conservative constituencies that they had gained at the end of the Civil War in 1865  and altered the party’s internal equilibrium and its electoral advantage, which had allowed it to continuously remain the majority in the House of Representatives between 1954 and 1994. The consequences of this transformation were gradual, in part due to the length of congressional careers, which last on average five terms (or ten years).  Over the course of the three decades that followed, conservative defectors from the Democratic Party proportionally strengthened its liberal factions. On the Republican side, the constituencies won in the South led to the strengthening of conservative forces within the Party and the gradual weakening of its moderate elements. The Republican’s electoral victory in Congress in 1994 (the “Republican Revolution”) was directly linked to massive Republicans gains in the South. In Congress, the majorities became increasingly homogenous internally, while differences across the aisle grew. 
8That factionalism was weakend within parties does not mean that it entirely disappeared. The Democratic Party remains divided between the Congressional Progressive Caucus, which represents its more liberal elements, the Blue Dog Coalition, which represents its more conservative elements, and the New Democratic Coalition, which represents centrist elements. Despite being more homogenous, the Republican Party is also divided into different conservative strands (fiscal, social, neo-conservative) and more moderate branches, such as the Republican Mainstream Partnership. The newest faction, which emerged on the national scene in 2009, is the Tea Party, a conservative libertarian group.  The movement’s emergence has reshaped the balance between the different Republican factions, without however transforming the basic dynamic that has existed for the past 30 years, which has seen the party radicalized around its conservative base. In general, the continued existence of internal factions in both parties does not prevent elected officials who belong to the same party from being ultimately quite similar. 
9In addition to more homogenous constituencies, the method for selecting political candidates has also become more marked by partisanship and ideology. This phenomenon can be explained by the power of the activist base in each party, working to nominate candidates during the primaries  and by the increased specialization of electoral funds that are channelled by political parties. The increased power of the activist bases within political parties and their role in promoting a more pronounced ideological framework were described for the first time in the 1960s.  When participative democracy measures were introduced, in particular primaries, the voices of the more militant individuals were heard more clearly, since these voters tended to be more politically engaged than the average member of the population.  From the 1960s, presidential candidates began to adopt more extreme political platforms, whether we consider the conservative Barry Goldwater in 1964 or the liberal George McGovern in 1972. With a closer focus on Congress, the work of political scientist Sean Theriault shows how the growing influence of party activists has led to the selection of candidates with more obviously ideological profiles.  The gradual replacement of moderate elected officials with more radical candidates became visible from the 1980s, and can be explained by the repeated defeat of moderates from both parties by more extreme candidates during primaries. Incumbents then tended to radicalize their own positions to better respond to this new crop of voters.  Even though this shift was more visible on the Republican side than on the Democratic side, which continued to include more diverse elected members, the proportion of moderates in both parties decreased in both the House and the Senate. Moderates were estimated to represent 60 per cent of the House of Representatives in the 1960s; this figure dropped to 25 per cent in 2004. In the Senate, the trend was the same: 53 per cent of those elected were considered moderates at the end of the 1960s, while this figure dropped to 33 per cent in 2004.  The election of Republican candidates backed by the Tea Party in 2010 logically followed this trend. The movement currently has about 50 elected members in Congress and has waged a constant campaign against the ACA that included the government shutdown in October 2013.
10Alongside the increasing radicalization of each party’s ideological base, changes in political financing – entailing both an increase in specialized electoral funds (by Political Action Committees, PACS, or Super PACs) and increasingly centralized party campaign funds – have also helped to strengthen partisanship. Over the course of the twentieth century, several studies have established a direct link between the autonomy of American legislators and the weak influence of political parties on political funding.  Since the 1980s, whether we look at national party committees or congressional campaign committees (Hill committees devoted to electing senators and representatives for a given party), partisan electoral organizations have significantly increased their campaign contributions, providing leverage that has allowed them to better control candidates.  The regulations that have been implemented since the 1970s regarding political funding and campaign finance – which limit direct donations to candidates or “hard money”, but remain silent about the funds that can be collected by parties for the purpose of party building campaigns (“soft money”) or independently by PACs – have accelerated this trend. The flexibility and fungibility of soft money and its absence of regulation have allowed the parties to assert their role as “service providers” to candidates  and to more closely manage their electoral campaigns. The Bipartisan Campaign Reform Act passed in 2002, also known as the McCain-Feingold Act, did not diminish the role of parties, but on the contrary bolstered it, even though its objective was originally to regulate and limit the use of soft money.  Although, as David Mayhew, the political scientist and author of a classic work on congressional members’ relationship with their constituents, has argued,  re-election is an ideal lens through which to examine the behaviour of American elected officials, the very conditions for re-election have changed. They are more ideological and the political parties orchestrate more media coverage. Today, elected representatives have a whole raft of motivations that force them to appear loyal to their party, to the detriment of the more pragmatic attitudes permitting compromise that had previously dominated Congress.
Reinforcing the partisan dynamic in Congress: the polarization of federal politics
11The strengthening of parties discussed above is at the root of the emergence of a more widespread partisan logic within the process of policy development. This phenomenon, particularly visible in Congress, has been called “partisan polarization” in the American literature.  Although this is now a recognized phenomenon, it does not affect all political domains in the same fashion. The recent work done by Bryan Jones and Ashley Jochim,  who studied the long-term impact of partisan logic on the different forms of intervention in Congress, has shown significant variation depending on the sector in question. Certain issues seem to be more diffuse in terms of partisan polarization– matters pertaining to agriculture, foreign affairs, scientific policy and transportation – while others aggravate partisan cleavages – such as issues concerning macro-economics, regulation, labour policy, worker protection, and redistributive policies such as healthcare. The policies that are the most resistant to partisan logic are those where the choices to be made by elected representatives involve multiple dimension and which cannot be reduced to the central Democratic/Republican cleavage with regard to the role of the state and its intervention in the economy. Policies that are more complex from the constituencies’ perspective – specific local or geographical issues, constituency interests, what these authors terms “multidimensional” issues – are more likely to divide legislators along lines that are not solely partisan or ideological. Such policies continue to follow the same pluralist logic that provided the driving force behind most congressional decisions until the 1980s. The more a political question is defined based on its distributive characteristics, the more it resists ideological integration or partisan appropriation. On the contrary, according to Jochim and Jones:
The issues with the simplest dimensional structures are those most directly associated with intervention in the economy, either through regulation, monetary and fiscal policy (labor, economics) or through major spending initiatives (health, housing). These are the arenas that have been the most aggressively organized by the political party system and subject to the most intense political scrutiny in contemporary American politics. 
13The strengthening of parties has led to the structuring of a growing number of political arenas along partisan lines; these have also more consistently been linked with the issue of the degree of state intervention in the economy. Jones and Jochim likewise observe that, since the 1980s, the dimensionality of policies affecting education, science, transport and health insurance has been simplified.
14For the political areas that are permeated by partisan ideology, the phenomenon of partisan polarization has transformed how public policies are shaped and reformed, and disseminated new approaches in a federal legislative process that had hitherto been necessarily pluralist in nature. Since the 1970s, the power relations between standing committees – the site of negotiations and the construction of temporary bipartisan coalitions on a sectorial base – and legislative parties have gradually shifted in favour of the latter. Following several waves of reform of Congress’ internal procedures, political groups gained the right to monitor nominations within the House and the Senate, as well as their presidencies, their working agendas and their organization. The Republican’s electoral victory in 1994 emphasized this trend: for the areas that polarized party opposition, this monitoring meant stricter control regarding the elaboration of proposed bills. In the House of Representatives, for example, it became relatively common for a party’s congressional campaign committee to replace the standing committees and centralize the development of legislative texts with the speaker’s staff.
15Joint sessions were likewise more frequently monitored and procedures that limited debate and the possibility of tabling an amendment were used more regularly.  Although until this point “closed” or “restricting” rules only represented a small proportion of the rules employed, and were limited to specific texts, such as fiscal and budgetary measures, today they are used for the majority of texts examined by the House of Representatives. Open rules used to represent 85 per cent, on average, of the rules applied by committees from 1979 to 1991; this figure fell to 50 per cent between 1993 and 2001, and since 2003 has reached a new low of 15 per cent on average.  In the Senate, where there are no rules governing debate as in the House of Representatives, increased control of sessions has taken the shape of the more frequent use of strategies attempting to bypass filibusters. The filibuster, a procedure that consists of extending the debate until a given reform fails, can only be defeated by a qualified majority of 60 senators out of 100 voting for cloture; it was routinely used from the 1990s as a tactic of parliamentary obstruction. Among dilatory motions, the prime example is the use of budgetary procedure, which allows substantial policy reforms to be passed in the form of a budget reconciliation bill only requiring a simple majority vote in both Houses.  Although it was originally restricted to budgetary matters, this technique has increasingly been used since the Reagan administration to pass laws dealing with fiscal issues as well as social and economic policy.
Types of rules adopted during joint sessions in the House of Representatives (1980–2012)
Types of rules adopted during joint sessions in the House of Representatives (1980–2012)
16The consequences of increased partisanship on the trajectory of policies are not universally accepted, and any long-term prediction is difficult. One hypothesis can be confirmed, however: the rise of parties is one factor behind the increased means and resources of authority in the hands of the majority, which can entail more frequent, structural reforms, and consequently alter the dynamics of political change in an unprecedented fashion.  In the context of health insurance policy, the subject of the next section, what we can observe is that the strengthening of parties since the 1990s has facilitated the passing of bills that have inflected these policies in a more conservative direction. Market logic was introduced to the liberal policies created in the 1960s and which had seemed to be “locked in” and impervious to change up until that point, such as Medicare.  In 2010, the ACA was likewise passed thanks to significant framing of the legislative process by legislative parties.
Health insurance policy through the lens of party politics
17From a qualitative point of view, several studies have reached a similar conclusion to that of the quantitative study by Jochim and Jones mentioned above: that of a partisan reformulation centred on the question of the federal government’s intervention in health insurance and the regulation of the private healthcare market. Although health policies have always been prone to cleavages, a renewal of partisan engagement in the issue became visible in the 1980s. In particular, this engagement was no longer limited to thwarting attempts at reforming the whole of the healthcare system, as had been the case before, but now also sought to attack policies that had met with relatively broad consensus among the political class in the past, such as Medicare. The political scientist Jonathan Oberlander  has shown that the consensus surrounding this programme since 1965 was overturned during the 1990s, when the actions of those in power shifted from attempts at policy management to attempts at more structural transformation. The changes observed were first fostered by the Republican Party, which abandoned the Keynesian premises that it had shared with its Democratic counterpart until the 1980s.
18The resurgence of partisan logic went hand-in-hand with a more closely monitored framework for reforms. The Balanced Budget Acts of 1995 and 1997, the Medicare Modernization Act of 2003, and 2010’s Affordable Care Act were all undertaken in different political contexts – in a unified government, a divided “cohabitation” government, and during different electoral periods – and gave rise to specific strategies, but they all nevertheless shared the fact that they were subject to framing by congressional campaign committees.
The Republican Revolution and a conservative turn for health policy
19Although it was absent during the Clinton reform in 1993-1994 – which had tried to create a universal healthcare system supported by the private insurance market and had prompted an extremely heated conflict between Congress’ various committees, leaders of the Democratic Party, and the White House  – supervision by legislative parties became much more visible after the Republican power shift in 1995. The Balanced Budget Acts of 1995 and 1997, as well as 2003’s Medicare Modernization Act, illustrate these practices. In a context where health expenditures were increasing astronomically, these reforms were an attempt to find a properly Republican path for the future, emphasising the ineffectiveness of the federal government and an unwavering faith in market logic. The Republican reforms undertaken in the 1990s and 2000s represent first and foremost an attempt at removing the state from the management of public health policy and at shifting the cost of healthcare onto individuals and the market.
The Balanced Budget Act of 1995: a Republican Congress united against the White House
20In 1995, the Balanced Budget Act (hereafter referred to as the BBA) was a priority for the 104th Congress. It was examined in a political context that was marked by the Republican victory in 1994, a triumph which saw the Party regain command of the legislative branch for the first time in 50 years. The Republican Party, then led by its controversial Speaker of the House Newt Gingrich, who had been one of the architects of Republican unification around a shared conservative platform called Contract with America, at the time appeared to be very cohesive. It supported reducing government involvement, in particular in social policies which were perceived to be having a negative effect on employment and the economy. The BBA’s scope went well beyond health policies alone. It was an important budget reconciliation law which sought to implement the Republican fiscal plan. The BBA planned to lower taxes by 245 billion dollars over seven years, while reducing state spending by almost 895 billion dollars. Among other social policies, Medicare and Medicaid were subject to important budgetary cuts of 270 billion and 163 billion, respectively. These cuts would consequently entail massive restructuring measures, be they the creation of medical savings accounts designed to encourage retirees to contribute to their health insurance plans; the partial privatization of Medicare, delegated to private insurance companies; or even the transformation of Medicaid into a system of capped subsidies given to individual states. Although Democrats were not fundamentally opposed to budget cuts, the extent of the cuts planned provoked their outrage, as well as the transformation of these policies’ instruments. The White House was likewise opposed to such measures and from the very beginning of the debate threatened to use its veto.
21Despite opposition from the Democrats and President Bill Clinton, Republicans refused any bipartisan compromise and tried to force the bill through. The reform’s formulation was controlled by Republican leaders, both during the committee review process and the joint session; the whole of the reform process took place in a partisan climate. In the House of Representatives, a working group steered by the office of the Speaker replaced the committees during the drafting of the text. The Republican congressional campaign committee’s meetings were closed to the public and to Democrats. It was only once the first version of the bill was fully drafted that the two competent committees with regard to health policy measures (Ways and Means and Energy and Commerce) were mobilized for a rapid amendment process, preceded by a single day of hearings.  Consideration of the bill was reduced to three days, all of the amendments proposed by Democrats were dismissed, and the committees approved the bill after a vote that was split along party lines. In the joint session, the BBA was granted a closed rule and the only amendment authorized was a Democratic alternative. In the Senate, the process was less tightly controlled by the Hill committees and the versions of the bill voted on were more centrist, in part because the Republican leader in the Senate, Bob Dole, was more moderate and distanced himself somewhat from his fellow conservatives in the House. However, due to the budgetary nature of the text, which deprived the Senate of the institutional leverage provided by filibustering, the Senate’s voice was rather weak on the issue. The joint conference committee was marked by partisan logic and significant ideological clashes. The Speaker presided over the conference committee,  which included only Republicans and was held immediately after the Senate bill was passed. After two weeks of negotiations, the House version of the bill prevailed and was incorporated into the report. On 17 November, after vehement debate, the two Houses passed the final bill.
22Bill Clinton let it be known that he would use his veto on the bill, but Republican leaders in both Houses refused to make any concessions. On the contrary, they adopted a confrontational stance towards the White House, threatening to not vote through the budgetary appropriations for 1996 that were necessary to finance the federal government’s operations. Clinton did not back down, and the government shut down twice, first between 14 and 19 November and then between 16 December and 6 January. The showdown between Congress and the White House ultimately worked against the Republicans, however, and the press called the latter obstructionists. Faced with increasingly unfavourable polls, Republican leaders finally decided to concede and postpone the budget reform project. The failure of the 1995 reconciliation bill was a major blow for Republicans and illustrated the limits of the political power of the leading party in the context of a divided government, while Bill Clinton came to be seen as a major veto player. 
The Balanced Budget Act of 1997: a bipartisan law bought by exercising significant control over the Republican majority
23There was a second attempt to pass a budget reduction bill in 1997, which occurred in a different political context. Following the elections in November 1996, the configuration of the political majorities had stayed relatively the same: Clinton had been re-elected, defeating former Senate majority leader Bob Dole by a comfortable margin, and continued to enjoy a high approval rate.  Opposite him, Republicans had conserved the majority but were weakened by the loss of several seats in both Houses. Nevertheless, after a 104th Congress characterized by high levels of conflict between Republicans and Democrats, both parties adopted a more negotiated strategy in order to put an end to legislative roadblocks that hurt them at the polls.
24With regard to its content, this second version of the bill preserved some of the measures that had been at the core of the 1995 bill: the partial privatization of Medicare and the creation of medical savings accounts, the cornerstone of the Republican health programme. Budget cuts were also included in the bill, although they were much more limited than those planned in 1995: Medicare would lose 115 billion dollars over five years and Medicaid would only lose 7 billion. The most controversial measures, concerning the transformation of Medicaid into a block grant state-funded programme, were abandoned. Medical savings accounts were likewise reduced to an experimental measure.  The 1997 version of the bill also included measures backed by Democrats and the White House, such as measures strengthening patient protection and coverage for preventative care, as well as one of the Clinton administration’s priorities: the creation of a new healthcare programme designed to covered uninsured children in families with incomes that were modest but too high to qualify for Medicaid. This programme was called the State Children’s Health Insurance Program (hereafter referred to as SCHIP). A former Clinton advisor explains:
In 1997, when Clinton was re-elected, he was in a position to push his own agenda and he did so very aggressively. Republicans simply could not say no. If they wanted to pass a Balanced Budget Act, they had to accept the compromise. Bill Clinton was very invested in SCHIP. He declared that he would veto the reform if it didn’t include this programme. The Republicans didn’t want the programme but they made the compromise in the reconciliation bill. There were negotiations on the exact shape that SCHIP would take: would this new policy be integrated into Medicaid? There were different models, too, and different issues were negotiated, such as the amount of flexibility states would have, and the capping of federal spending. 
26The shape that SCHIP ultimately took attests to these negotiations: the new policy took the form of a global donation of 20 billion dollars to the states limited to seven years (a block grant), at the end of which, contrary to Medicare and Medicaid which are permanent federal commitments, SCHIP would need to be voted on again by Congress. The federal government’s minimal commitment was one of the conditions behind incorporating this new policy into the reconciliation bill. A former advisor to Newt Gingrich recalls the negotiations that took place between the White House and leaders in Congress:
In 1997, we absolutely had to pass the law. Republicans could no longer allow the government to shut down and the White House knew it. These were very difficult negotiations, especially with regard to health policies. But ultimately, we reached an agreement, primarily because we ended up spending a lot more than we had intended to. SCHIP is one example. A fair number of Republicans said that the terms of this agreement were not very good, because we ended up spending more money than we wanted to, and by extending a federal policy rather than curtailing it. 
28In Congress, the more conservative elements protested the terms of the agreement reached with the White House, and preserving their support became a challenge for Republican leaders. As in 1995, the legislative process was centralized by the legislative parties. The drafting of the first version of the bill took place in the Speaker’s office  and it was only later that other committees were involved, primarily to ratify the agreement reached with the White House. Republican leaders filed the bill in June. With regard to health policy measures, the Ways and Means Committee approved the bill unanimously and almost immediately.  Discussions were longer in the Energy and Commerce Committee, where the bill was met with more opposition, but the Committee ultimately voted for the bill 29 against 17, with only two Democrats voting for it. In the Senate, the Committee on Finance voted for the bill unanimously. Although the Committee examined over 200 amendments, the original version of the bill as drafted by the House of Representatives prevailed and the terms of the agreement reached between Clinton and Republican leaders were preserved. During the meetings of the joint conference committee, negotiations were limited to Republicans from both Houses and the White House. The final vote took place a month after the plan had been made public. The House voted for the conference committee’s report 346 against 85; 32 conservative Republicans went against their own party and 53 Democrats voted against the bill. The Senate passed the bill 85 to 15.
29The 1997 BBA was a process requiring more negotiation than its 1995 counterpart, primarily between the Hill committees and the White House, but similarities appear between the two legislative processes. The standing committees were relatively marginalized in both cases. What was remarkable about the 1997 reform is that both parties managed to maintain enough partisan discipline to pass the bill. From this point of view, this reform, despite its bipartisan nature, reveals the important framing undertaken by the congressional campaign committees. The 1997 Balanced Budget Act illustrates a case where their impact is shown by the fact that Republican leaders managed to convince enough conservatives to vote for a bill that contained a significant increase in public spending. The 1997 BBA nonetheless tarnished the unified front presented by the Republican majority. Fiscal conservatives publicly criticized the concessions made to the Democrats. These criticisms were focused on Speaker Gingrich and constituted one of the reasons behind his resignation in 1998.
The 2003 Medicare Modernization Act: Republicans in charge
30The 2003 Medicare reform was characterized by several observers as one of the most important changes to Medicare since its creation in 1965.  It was also the first change that occurred under a Republican government and was an occasion for the Republican Party to propose structural changes in an area traditionally seen as Democratic turf. With regard to its substance, the reform sought to extend the partial privatization of Medicare by contracting health insurance companies (Medicare Advantage). A second modification, which was the one that received the most media coverage at the time, was the introduction of voluntary enrolment in an entitlement benefit for prescription drugs, likewise run by private insurance companies. The political context surrounding the reform was one of unified government, where both the Congress and the White House were Republican. And yet despite this configuration, the narrow Republican margin in Congress required bipartisan negotiations, in particular because the reform could not be passed as a budget reconciliation bill, unlike the BBA. This meant that negotiations with Senate Democrats, where the Republican majority was 51 out of 100, were necessary to prevent a filibuster. There again, a major issue for the group was maintaining enough cohesion among its different factions, not alienating fiscal conservatives while still preserving the support of a handful of Democrats.
31During the legislative process, standing committees were more autonomous than when reforms were passed in the 1990s. In the House of Representatives, this autonomy was embodied in the leadership of the Ways and Means Committee’s president, Bill Thomas. The committee ensured a more traditional role of general control over the reform process. The autonomy that Bill Thomas enjoyed was not total, however: it was based on the guarantee that he would provide the kind of reform that the Republican campaign committee expected:
I guaranteed the legislative party that I would provide them with a reform that would involve the market more, that would create a new entitlement benefit for prescription drugs, and that would not cost more than 395 billion dollars, because the president had said that we only had 400 billion dollars to spend. The party had no real interest in the details and concrete mechanisms, what was important to them was that the reform would be based on market logic. So they left me free to do what I wanted. They were involved in some parts of the reform. Speaker Hastert for example was very attached to the idea of health savings accounts. He was also invested in the fact that the market would determine the price of medications, rather than some administrative structure. But he had neither the time nor the energy to control the whole process. 
33The priority of House leaders was imposing a conservative reform bill, which would set the tone for negotiations with regard to the Senate’s version. It was to be consistent with the individual approach to health insurance, strengthening the health savings accounts measure that had been introduced in the 1990s. Once the bill was elaborated, the committees amended and voted on it following party lines and according to majority logic. In the joint session, a closed rule was applied, only Democratic alternatives were authorized and debate was limited to three hours. Despite not obtaining any kind of agreement from the Democratic side, the text managed to squeak by, 217 votes to 216. A former advisor to the Ways and Means Committee recalls the difficulties experienced by Republican leaders at the time:
Some members of the committee supported the reform, about a hundred or so, but we also had something like 50 members who were difficult, problematic. Some of them supported certain options on principle, for example Paul Ryan supported the competition measures linked to Medicare, and others wanted health savings accounts to be strengthened. That, we did. Other members on the other hand didn’t care about the content at all, they just cared about the hospitals in their district… For example, we had a very specific question about Iowa hospitals. But once we got the hospital associations with us, that sort of greased the wheels… And then, there were also a few elected members who opposed what we were doing on principle, regardless of the shape it would take, they just did not want to increase public spending no matter what. They opposed the bill, in whatever form it took. There was no way to convince them. 
35While Republicans in the House of Representatives had pushed for a more conservative version of the bill, the Senate produced a more moderate, bipartisan law. The legislative process was marked by negotiations within the Committee on Finance between Republicans and moderate Democrats, whose votes were necessary to garner the support of 60 senators. In a joint declaration, Chuck Grassley, the President of the Committee on Finance, and the Democratic leader in the Senate, Max Baucus, announced that they had reached a compromise. The committee voted the same day, in very large proportion for the bill (16-5). The same bipartisan climate existed when the bill was voted on in the joint session; the reform was passed in the upper House by 76 to 21 votes.
36The joint conference committee met between July and November 2003 to negotiate an agreement on a bipartisan version of the bill. The negotiations that unfolded this time quickly regained their partisan nature and excluded House Democrats entirely. Only a handful of conservative Democrats from the Senate were allowed to participate. During these negotiations, the most conservative measures in the bill were removed from the final text in order to preserve the support of the Senate Blue Dog Democrats. The former president of the Ways and Means Committee describes the process:
We pushed it as far as we could and we spent as much as we could to keep the conference unified. Once we reached an agreement, we reported it to Congress. In the Senate, the joint conference committee’s report was passed through relatively easily. In the House of Representatives, this was much more difficult because there were very few Democrats who supported the reform. They would have suffered reprisals from their party leaders if they had let another prescription drug benefit plan pass with a Republican majority. 
38The vote in the House of Representatives took place during the night of 22 to 23 November; 220 representatives voted for the bill and 215 voted against it. Twenty-five conservative Republicans defected from their party and sixteen Democrats voted for the bill. During the vote, the leaders of the committee put pressure on several Republicans to change their vote and kept the session open beyond the regulatory 15-minute limit, for a period of three hours in total.  This was described by a journalist from the Washington Post:
Meantime, Health and Human Services Secretary Tommy G. Thompson, who had been working the Capitol all day, defied custom and moved onto the House floor. He and Hastert avoided the back rows where many of the conservatives were clustered, and targeted “no” voters such as Reps. John Shadegg (R-Ariz.) and Nick Smith (R-Mich.), who were standing or sitting alone. The broadshouldered speaker, moving through the crowded aisles like a fullback, plumped down next to Smith, who is retiring next year after 40 years in a succession of public offices. Hastert threw an arm around Smith’s shoulder and leaned in as Thompson moved into the seat on the other side. Aides recounted that Hastert said Smith’s help was vital to the party and the president – a fitting gift at the end of a long career – and suggested it would also help Smith’s son, who plans to run for the seat. 
40In the Senate, the bill passed on 25 November, 54 to 44; nine Republican senators broke with party lines, including former majority leader Trent Lott, who had ceded his place to Bill Frist in 2002. Those lost votes were made up by eleven Blue Dog Democrats who voted for the bill. All in all, the Medicare Modernization Act reveals the important partisan framework furnished by the more conservative factions, which were opposed to the expansion of Medicare through the creation of a prescription drug benefit. Much like the BBA in 1997, one of the main difficulties that the committee leaders experienced was preserving the unity of the group with regard to measures that deviated from the Republican agenda.
Obamacare and partisan polarization
41The 2010 Patient Protection and Affordable Care Act was one of President Barack Obama’s most significant legislative achievements during his first term. From the perspective of the reform’s political context, existing studies all mention a “window of opportunity”,  characterized by significant support from the population at large and special interest groups in particular,  as well as from well-inclined political majorities. The reform unfolded in a context where the healthcare system was completely unravelling, both from an economic and a social point of view. From an economic perspective, despite Republican reforms, healthcare costs had continued to rise steadily, by 4 per cent in 2009, by 4.7 per cent in 2008, and represented 16 per cent of the GDP.  The problem was especially severe in 2008-2010, when an important economic and financial crisis hit the United States. From a social perspective, unequal access to care became a growing issue and the number of uninsured (or underinsured) individuals swelled. While 38 million people did not have health insurance during the first half of the 1990s, this figure had reached 45 million in 2008. That year’s economic crisis grew the ranks of the uninsured. At the same time, Medicaid and other social programmes had recently suffered budget cuts and were thus incapable of absorbing the increasing number of recession victims affected by homelessness and poverty.  This second failing aspect of the American healthcare system was an important topic of public debate in 2008, and in general has garnered significant media attention from the second half of the 2000s. The continued deterioration of the health system in terms of both access and cost, especially as exacerbated by the financial and economic crisis of 2008-2010, helped to lay the ground for 2010’s reform.  These elements all helped to foster public anxiety and increase demands for greater public intervention. The failures of the health market likewise helped to establish broad support across the sector’s economic groups.
42Although the reform did not radically transform the American healthcare system, in the sense that it did not fundamentally redefine the balance between the public and private sectors, it nevertheless did introduce important new measures which globally changed the face of health policy.  First of all, it significantly reinforced the regulations and controls imposed on the healthcare market. It transformed the conditions of the competition between insurers by creating a certification process which would allow different private agents who respected the new federal regulations (minimum benefits, no discrimination based on preexisting conditions) to offer their services to individuals and small businesses through health insurance marketplaces. The reform also relied on the creation of an individual mandate for insurance, as in the Netherlands, which was designed to put an end to adverse selection processes, where only those individuals needing medical care bought health insurance. A fine of a limited amount would be applied to households without insurance. To help offset this individual mandate, federal subsidies were created to give low-income households the financial means to purchase health insurance, primarily through the expansion of Medicaid and tax credits.
A partisan legislative process
43The size of the Democratic majority in Congress, and especially in the Senate where Democrats held the 60 seats necessary to prevent filibustering, had a significant impact on the reform process. It meant that the Democrats did not have to negotiate with Republicans and that the main challenge involved in the legislative process was maintaining cohesion within a relatively diverse majority.  The 2010 process was organized by the congressional campaign committees and was highly polarized, while Republicans violently attacked a bill that they found to be an unacceptable expansion of involvement by the federal government. The 111th Congress was described as one of the most polarized in the history of the United States, and the ACA crystallized the clashes between the two parties.
44The legislative process began in the spring of 2009. In the House of Representatives, the three competent committees – Energy and Commerce, Ways and Means, and Education and Labor – worked together within a platform controlled by the Democratic leadership, from which Republicans were excluded. It was only later that the other standing committees of jurisdiction were mobilized.  During the drafting of what was later called the Tri-Committee Bill, the teams behind speaker Nancy Pelosi controlled negotiations regarding the more controversial aspects of the reform bill. Just as when the Republicans had been in power, the group strategically managed the work conducted, and centralized negotiations with the sector’s special interest groups.
45The Tri-Committee Bill was made public in June 2009 and reported to each of the relevant committees for examination and amendment. The bill was liberal in orientation and bore witness to the influence of the Democratic leadership, whose strategy had been to propose the most liberal version possible, to balance the more moderate version that the Senate would have to pass on account of the Blue Dogs’ political clout. The Tri-Committee Bill included one of the most controversial elements of the debate that raged at the time: the public option, supported by the liberal representatives in the House. This was a public programme that was supposed to compete with private agents on the health insurance marketplace. The idea was that this kind of programme, having the administration’s backing, would be able to offer less expensive insurance policies and would consequently force private companies to lower their premiums in the hopes of remaining competitive. The bill also included provisions controlling the prices that could be charged by health professionals and the pharmaceutical industry, while moreover expanding Medicaid to cover individuals whose income was below 150 per cent of the federal poverty line.  However, the House’s Blue Dogs, who were sufficiently numerous to force the reform to fail if they massively opposed it, obtained several concessions. The public option was weakened and the new regulations were stripped of any kind of price control mechanism. The Blue Dogs also obtained a reduction in federal subsidies and measures limiting the rights of undocumented foreigners. The bill was debated on 7 November under a closed rule. No amendment was authorized, except for a Republican alternative. At the close of a heated debate, where Republicans employed extreme rhetorical tactics to attack the bill, the House version passed, 220 votes to 215. Thirty-nine moderate Democrats voted against their party and all of the Republicans voted against the bill.
46In the Senate, the role of Democratic leaders was less visible, and seemed more transactional at first.  As in the House of Representatives, work began in the spring of 2009. But contrary to what happened in the House, where Republican opposition emerged immediately, the committees started with bipartisan negotiations. These primarily took place within the Committee on Finance, whose president Max Baucus had supported the 2003 Medicare reform. However, these negotiations failed. The search for a compromise in order to gain the support of a few moderate Republicans caused delays in the bill’s development and Baucus gradually lost his backing by moderate Republicans: only one senator voted for the measure in the Committee, but she ultimately revised her opinion in the full session after being pressured by the Republican party. According to a staffer working for the Republican committee in the Senate, negotiations between Baucus and moderate Republicans were closely monitored. The Republican party’s position was clear: it was opposed to any Democratic reform.
The senators who negotiated with Baucus very regularly met up with the committee’s leaders. From the beginning, we asked them to not reach any agreement with the Democrats without telling us about it. They promised to not take any decisions without first discussing it with us. Moreover, it was immediately apparent that if they agreed to the compromise offered by the White House and Baucus, they would be alienated: they would not be able to convince any other Republican senators to follow them. There was no one in the committee who would have supported this deal. Under these conditions, they knew that it was not worth it to pass a compromise, they would have put themselves in danger if they alone voted alongside the Democrats. 
48The summer of 2009 brought an additional stage in the politicization of the legislative process. Republicans and other conservative political forces attacked the bill and denounced it as an attempt to “socialize the health care system”. This rhetoric had a certain impact on public opinion, whose support for the reform dropped.  Faced with a serious risk of stalling, the month of September marked the end of the autonomy that the Senate’s committees had enjoyed and the Democratic leadership regained control of the proceedings. The strategic centre of negotiations shifted from the Committee on Finance to the teams behind Senate majority leader Harry Reid. The version that the Committee on Finance finally proposed was more moderate than the one voted through in the House of Representatives: it preserved the marketplace concept but weakened federal regulations and the expansion of Medicare, and eliminated any mechanism for price control and monitoring. Finally, it replaced the public option with private insurance co-ops managed by their insured members, much like a European mutual company [mutuelle]. The Committee voted in favour of the bill on 13 October. The Democratic leadership then assumed the management of the legislative process once more. Several substantial measures were added to the bill at this point. The public option was reinstated, mitigated however by granting states the option not to participate in this system. The voluntary expansion of Medicare for those aged 55 or above (the Medicare buy-in option) was also present in the reform. However, this more liberal version of the bill provoked the opposition of the Blue Dog Democrats and Reid ultimately had to backpedal: the public option was once again removed from the bill, as were the Medicaid expansion measures. Finally, on 17 December, at the end of a strictly partisan vote of 60-40, in which no Democrat opposed the bill, Reid obtained cloture of the debate. The bill was voted on 24 December, 60 senators for and 39 against the bill.
49The joint conference committee was likewise characterized by partisan logic. The presidents of the standing committees and the leaders of the Democratic group were called to the White House to work on drafting a joint version of the bill. An advisor for the Energy and Commerce Committee recounts the experience:
We didn’t follow the regular procedures at all. If we had done that, the reform would have probably not passed: in the Senate, the problem was that the list of provisions had to be voted on by the qualified majority of sixty senators. In the House, there were also some procedural problems: even if the House operates under simple majority rule, the minority is allowed to present “motions to instruct”. This means that those provisions would have to be explained with regard to measures contained in the report. The Republicans would have asked questions to make the Democrats uncomfortable. This would have risked splitting the group apart. So in order to avoid this situation, the Democratic leaders simply decided that there would be no formal conference. In its place, we had an informal process, which was not transparent and not public. 
51No Republicans were allowed to participate in the negotiations, which took place behind closed doors between the end of December and the beginning of March. Meanwhile, however, a Senate by-election in Massachusetts caused the Democrats to lose their sixtieth seat.  In order to avoid any filibustering when Congress moved to vote on the report produced by the joint conference committee, both Pelosi and Reid tried to avoid a new Senate vote and chose to pass the version already voted on by the Senate to the House of Representatives, thus in fact repealing the version that the House had itself passed in November. It was decided that the House’s amendments would be passed under a budget reconciliation bill. These changes were relatively minor and the main sources of conflict within the majority (the public option and price control mechanisms) were left aside.
52The joint session debates were as contentious as they had been when the bill was first drafted, despite the fact that it was now a centrist version that was being put to the vote. The bill was examined under a closed rule and only authorized a Republican alternative that would act as a substitute. In the House, the vote was 219 against 212. No Republican voted in favour of the bill and 34 conservative Democrats voted against it. The reconciliation bill was voted on immediately following and passed 220 to 207. Two Republicans and one Democrat abstained, no Republican voted for the bill and 32 Democrats voted against it. Despite the defection of a number of Blue Dogs, the Democrats managed to gather enough votes to adopt the reform.
53* * *
54Since the reform was passed in 2010, the ACA has continued to crystallize the clashes between the two parties. The morning after its adoption, Republicans introduced a bill seeking to repeal Obamacare, and attempts at repeal have been ongoing since then. In March 2014, 54 attempts at partial or total repeal of the ACA were voted on favourably in the House of Representatives, which has held a Republican majority since November 2010. To this day, these measures have all been blocked by the Senate, which remains under Democratic control. A recent attempt was proposed in January 2014  by senators Hatch, Burr and Coburn which sought to present a Republican alternative to Obamacare for the mid-term elections in November 2014. This proposal repealed the individual mandate and the majority of regulations for insurance providers; federal subsidies were likewise reduced, as was the expansion of Medicaid. Such attempts at repealing Obamacare have been supported by a constant campaign of opposition to the reform, primarily financed by funds from conservative movements. The amount spent on television campaigns, both in favour or against the bill, has reached 500 million dollars, and projections estimate that by 2015, this sum will reach one billion dollars. 
55In the current situation, however, these attempts at repeal are unlikely to pass, for reasons that are both political and economic. Politically speaking, the chances of a repeal bill succeeding are extremely slim for the next two years. The same partisan polarization that helped to pass the 2010 reform is currently working against Republicans and is protecting the bill, at least in the short term, thanks to the institutional barriers presented by the American political system. Support for the repeal of Obamacare among special interest groups in the sector is also far from being a given, despite Republican lobbying attempts. This is an essential difference and a historical break with the political configurations that were observed during previous reform attempts. Republican attacks lack the support of interest groups and rely primarily on conservative activist groups. Health insurance companies are already heavily committed to implementation, including in the health insurance marketplaces, and backtracking would be costly for them. Doctors are likewise actively involved, especially at the state level. Employers are not opposed to the reform either, although many do seek to negotiate more favourable measures.  Moreover, the costs – both political and economic – associated with returning to the previous situation are increasing every month, as a growing number of Americans benefit from the new services and regulations. In such a landscape, Republican actions are primarily directed towards the 2014 mid-term elections. Even though it is unlikely, the repeal argument will be a major campaign theme for them.
56In addition to providing a commentary on a current political event, in terms of public policy, the level of politicization that surrounded the ACA made its passing into law more uncertain in one sense, and more surprising as well, to the extent that it contradicts the established certainties of American policy-making – in particular the essential role played by the “centre” in the success or failure of a given reform. The system of checks and balances that characterizes the American political system is supposed to encourage a bipartisan political process and move all legislation towards the centre or the position of the “median legislator”.  These mechanisms continue to play a major role, forcing the parties to negotiate, as was the case for the health reforms conducted in 1997 and 2003. However, in the case of the ACA, what we observe is not an institutional impasse caused by a lack of bipartisan consensus, but on the contrary the pushing through by force of a purely Democratic bill, from which Republicans were excluded. As Hacker and Pierson have observed,  partisan polarization is less likely to produce an institutional impasse than a growing number of “off-centre” reforms; that is to say, those which move increasingly further away from the centre or any sort of median legislative ideal, to move closer to the centre of the ruling party. These off-centre policies – one example of which, according to Hacker and Pierson, were the budget cuts passed during George W. Bush’s first term – rely on stronger partisan identities, on the centralisation of the decision-making process by partisan leaders and the White House, and on a total refusal to co-operate with the other party.
57The ACA is an almost perfect embodiment of this type of off-centre policy, not so much in terms of its content but rather its process. The reform was the fruit of internal compromises within the Democratic Party, much more than it was the result of bipartisan negotiations, as attests the vigour with which Republicans continue to attack the law. It was able to be voted through because the Democratic majority in Congress remained cohesive, and because the whole of the reform process was closely structured and monitored by Democratic leaders from both Houses. Most of the time, Republicans were excluded from the legislative process, while attempts at negotiation led by Max Baucus to gather the support of moderate Senate Republicans threatened to topple the entire legislative process. It follows that, in a unified government, political majorities seem to be more capable of imposing controversial bills today. Consequently, one of the main observations of this article relates to the fact that a reform that was controversial for decades became possible, in part due to transformations in the processes of formulating and reforming policies.
58From this stems the hypothesis that there now exists a greater level of awareness of majority logic in the policy-making process, which can lead to more frequent and more structurally different policies in the case of a unified government, but also to increased impasses in a divided government, when the two Houses of Congress and the White House are not occupied by the same party and adopt a confrontational stance.  The 2013 federal government shutdown is a perfect illustration of this risk. These changes are not necessarily permanent, but as Hacker and Skocpol have shown,  the reinforced weight of ideology, increased specialization in campaign funds, in particular through party machines, and the trend towards radicalization among federally elected representatives remain pressing issues today, and all suggest that the logics observed in the context of recent health policy reforms will continue to play a crucial role in the future. 
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Cf. in particular Alexander Hicks, Joya Misra, “Political resources and the growth of welfare in affluent capitalist democracies, 1960-1982”, American Journal of Sociology, 177, 1993, 668-710; Evelyne Huber, Charles Ragin, John D. Stephens, “Social democracy, Christian democracy, constitutional structure, and the welfare state”, American Journal of Sociology, 99(3), 1993, 711-49.
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B. Sinclair, Unorthodox Lawmaking.
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Interview conducted with a former health policy advisor to Bill Clinton, 30 April 2010.
Interview conducted with a former advisor to Newt Gingrich, 28 May 2009.
Interview conducted with a former advisor to the Ways and Means Committee, 15 May 2009.
“Big Medicare, Medicaid changes enacted in budget bills”, CQ Almanac 1997.
Timothy Stoltzfus Jost, “The most important health care change of the millennium (so far), the Medicare Modernization Act”, Yale Journal of Health Policy, Law, and Ethics, 5, 2005, 437-45.
Interview conducted with a former president of the Ways and Means Committee, 8 June 2009.
Interview conducted with a former director of the Ways and Means Committee’s sub-committee on health, 26 April 2010.
Interview conducted with a former president of the Ways and Means Committee, 8 June 2009.
Andrea L. Campbell, Kimberly Morgan, “The shifting line between public and private. The politics of the 2003 Medicare Modernization Act and Prescription Drug Reform”, Social Science History Association Annual Meeting, 3, 2005, 187-219.
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Larry D. Brown, “The elements of surprise. How health reform happened”, Journal of Health Politics, Policy, and Law, 36(3), 2011, 419-29; Lawrence R. Jacobs, Theda Skocpol, Health Care Reform and American Politics. What Everyone Needs to Know (New York: Oxford University Press, 2010).
Jill Quadagno, “Interest-group influence on the Patient Protection and Affordability Act of 2010. Winners and losers in the health care reform debate”, Journal of Health Politics, Policy, and Law, 36(3), 2011, 449-53; Miriam J. Laugesen, “Civilized medicine. Physicians and health care reform”, Journal of Health Politics, Policy, and Law, 36(3), 2011, 507-12.
These figures were made public by the Center for Medicare and Medicaid Services, in a report published in February 2010, titled “The national health expenditure account”. These are the official data regarding health expenditures in the United States.
For a more in-depth analysis on the sociology of the uninsured, see the series of reports published by the Kaiser Family Foundation. For example: “The uninsured, a primer, key facts about Americans without health insurance” (October 2009).
L. R. Jacobs, T. Skocpol, Health Care Reform.
Carolyn H. Tuohy, “American health reform in comparative perspective. Big bang, blueprint, or mosaic?”, Journal of Health Politics, Policy, and Law, 36(3), 2011, 571-6.
The Blue Dog conservative faction was made up of 55 Democrats in the House of Representatives and between ten and fifteen senators in the upper House. This group opposed proposals entailing significant intervention by the federal government on several occasions.
Interview conducted with an advisor for the Education and Labor Committee, 10 May 2010.
“Landmark health care overhaul: a long, acrimonious journey”, in Jan Austin (ed.), CQ Almanac 2009, 65th edn (Washington: CQ-Roll Call Group, 2010), 13.3-13.14.
Vincent G. Moscardelli, “Harry Reid and health care reform in the Senate. Transactional leadership in a transformational moment?”, The Forum, 8(1), 2010, 1-24.
Interview conducted with an advisor to minority leader Mitch McConnell, 6 May 2010.
Lydia Saad, “Americans still sharply divided on healthcare reform”, Gallup Politics, 8 September 2009.
Interview conducted with an advisor to the Energy and Commerce Committee, 1 April 2010.
This was the January 2010 election, where Scott Brown won the seat left vacant by Ted Kennedy in Massachusetts.
This article was originally published in French in 2014.
Elizabeth Wilner, “The first $1B TV ad issue since SS, Medicare”, Kantar Media, University of Wisconsin, 7 August 2013.
Joel Ario, Lawrence R. Jacobs, “In the wake of the Supreme Court decision, many stakeholders still support the Affordable Care Act”, Health Affairs, 31(8), 2012, 1855-65.
Keith Krehbiel, “The party effect from A to Z and beyond”, Journal of Politics, 61(3), 1999, 832-40.
J. S. Hacker, P. Pierson, Off Center.
K. J. Morgan, “Obstruction ou réforme?”.
Jacob S. Hacker, Theda Skocpol, “The new politics of US health policy”, Journal of Health Politics, Policy, and Law, 22(2), 1997, 315-38.
This article draws from several studies conducted in the context of the ANR-Opera research project directed by William Genieys (Cepel, Montpellier-I): ANR-08-BLAN-0032 (Operationalizing Programmatic Elites Research in America, 1988-2008).