The politics of healthcare access: how policy feedbacks affect the sustainability of policy change

According to a recent Census report, since the Affordable Care Act (ACA) was passed in 2010, the rate of individuals without health insurance in the United States increased two years in a row in 2018 and 2019. If the Affordable Care Act was designed to ensure that all Americans had health insurance, why and how is the policy failing to serve that purpose? Healthcare in the Netherlands, by contrast, is provided through a structure similar to the ACA, and yet such problems of declining coverage have not occurred. A unitary parliamentary structure and a corporatist tradition of relationships between the Dutch government and interest groups allowed policymakers to design a healthcare reform with fewer moving parts that better fit together. My dissertation examines three questions. First, how do institutional differences between the United States and the Netherlands generate differing feedback effects in the two countries? Second, how does partisan polarization affect the mobilization of interest groups and the perceptions of healthcare policy makers and stakeholders? Three, how do ACA-exempt plans affect benchmark premiums in ACA exchanges? My dissertation focuses on STLDIs as the main vehicles by which the Trump administration undercut the usefulness of the ACA. Understanding policy feedback effects in healthcare policymaking reveals mechanisms that determine why some policies are sustainable and durable while others fail. On the question of sustainability of the ACA, policy feedback frameworks provide useful tools. It is clear that the ACA has been undermined by such negative feedback effects as high deductibles in the ACA-compliant plans. The Trump administration used ACA-exempt plans in part to expand access to health insurance, since ACA-compliant plans are unaffordable to many Americans who are just above the 400% federal poverty level. In doing so, it ignored the issue of access to healthcare services since ACA-exempt plans do not have to provide essential benefits. Democrat-controlled states took various measures such as complete ban in some states, limitation on their duration, ban on online sales to protect consumers from ACA-exempt plans. Hospitals and the insurance industry were largely opposed to Trump administration efforts to make STLDIs widely available because they foresaw fragmentation and destabilization of insurance markets and a rise of unpaid hospital bills. On February 15, 2021, newly elected President Biden signed an executive order instructing federal agencies to reverse the Trump’s administration rules on the ACA-exempt plans. My research addresses the question of healthcare policies’ sustainability by arguing that the institutional characteristics of the U.S. political system make it painfully difficult to design a reform that is sustainable. Among many obstacles are low trust in government among many Americans and the abundance of veto points in the policymaking process.Ph.D.Includes bibliographical reference