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Health Reform in the Trump Era: Will Politics Unmake Policy?

  • Andrew S. Kelly EMAIL logo
From the journal The Forum


Donald J. Trump’s unexpected victory in the 2016 presidential election cast a long shadow over the American welfare state. With continued Republican control of the House and Senate, Trump’s occupancy of the Oval Office removed a critical constraint on Republican efforts to dismantle key Democratic social policy achievements—both old and new. Despite the absence of these important institutional veto-points, the policies that were first identified and targeted by Republicans during the Trump era have proved to be more robust than many observers and policymakers initially believed. By applying the theoretical insights and methodological tools of American Political Development, this article explores how long-running policy processes have altered the political landscape in often underappreciated ways to narrow the prospects for large-scale policy reform. More specifically, this article examines the political dynamics of Medicare and the Affordable Care Act in the early days of the Trump administration. The pressures exerted on both programs by an unpredictable president and unified Republican control of Congress provides a unique opportunity to differentiate between and assess the prospects for policy sustainability and policy stability.


The author would like to thank Philip Rocco, Adam Sheingate, Daniel Galvin, and the editors of Forum for their helpful comments and suggestions.


AARP. 2017. “AARP Opposes Special Interest Health Care Bill.” AARP Press Release, March 7, 2017.Search in Google Scholar

Amash, Jordan. 2017. Twitter, March 6. in Google Scholar

Americans for Prosperity. 2017. “AFP Grassroots Convenes on U.S. Capitol at Obamacare Repeal Rally.” AFP, March 8. in Google Scholar

Bachrach, Deborah, Patricia Boozang, and Mindy Lipson. 2015. “The Impact of Medicaid Expansion on Uncompensated Care Costs: Early Results and Policy Implications for States.” The Robert Wood Johnson Foundation, June, 2015.Search in Google Scholar

Berman, Russell. 2017a. “The Republicans Trying to Slow Down Obamacare Repeal.” The Atlantic, January 9.Search in Google Scholar

Berman, Russell. 2017b. “The Conservative Uprising Against the Republican Health-Care Bill.” The Atlantic, March 6.Search in Google Scholar

Brown, Charles, Steven B. Fisher, and Phyllis Resnick. 2016. “Assessing the Economic and Budgetary Impact of Medicaid Expansion in Colorado: FY 2015–2016 through FY 2034-35.” The Colorado Health Foundation, March 2016.Search in Google Scholar

Bryan, Bob. 2017. “Insurance Companies are Freaking out about Trump’s Obamacare Threats.” Business Insider, April 28, 2017.Search in Google Scholar

Campbell, Andrea Louise. 2015. “Independence and Freedom: Public Opinion and the Politics of Medicare and Medicaid.” In Medicare and Medicaid at 50: America’s Entitlement Programs in the Age of the Affordable Care Act, edited by Alan B. Cohen, David C. Colby, Keith A. Wailoo, and Julian E. Zelizer, 147–67. New York: Oxford University Press.Search in Google Scholar

Findlay, Steven. 1997. “Seniors, HMOs Worried About Federal Tinkering.” USA Today, May 15.Search in Google Scholar

Garrett, Bowen, and Anuj Gangopadhyaya. 2016. “Who Gained Health Insurance Coverage Under the ACA, and Where Do They Live?” Urban Institute, December, 2016.Search in Google Scholar

Goldstein, Amy. 1999. “Health Care Financing Administration; Medicare ‘Competition’: Not in Theiry Backyard.” Washington Post, August 13.Search in Google Scholar

Grossmann, Matt, and David A. Hopkins. 2015. “Ideological Republicans and Group Interest Democrats: The Asymmetry of American Party Politics.” Perspectives on Politics 13 (1): 119–139.10.1017/S1537592714003168Search in Google Scholar

Hacker, Jacob S. 2004. “Privatizing Risk without Privatizing the Welfare State: The Hidden Politics of Social Policy Retrenchment in the United States.” American Political Science Review, 98 (2): 243–60.10.2307/j.ctv1mjqv11.19Search in Google Scholar

Hacker, Jacob S. 2005. “Policy Drift: The Hidden Politics of US Welfare State Retrenchment.” In Beyond Continuity: Institutional Change in Advanced Political Economies, edited by Wolfgang Streeck and Kathleen Thelen, 40–82. New York: Oxford University Press.Search in Google Scholar

Hacker, Jacob S. 2010. “The Road to Somewhere: Why Health Reform Happened.” Perspectives on Politics 8 (3): 861–876.10.1017/S1537592710002021Search in Google Scholar

Harrington, Rebecca. 2017. “Billionaire Koch Brothers are Promising Millions to Republicans that Help Sink ‘Trumpcare.’” Business Insider, March 23, 2017.Search in Google Scholar

Hellmann, Jessie. 2017. “Four GOP senators pledge to vote against rolling back Medicaid expansion.” The Hill, March 6.Search in Google Scholar

Jost, Timothy. 2017. “House Passes AHCA: How It Happened, What It Would Do, And Its Uncertain Senate Future.” Health Affairs Blog, May 4.Search in Google Scholar

Kelly, Andrew S. 2016. “Boutique to Booming: Medicare Managed Care and the Private Path to Policy Change.” Journal of Health Politics, Policy and Law 41 (3): 315–354.10.1215/03616878-3523934Search in Google Scholar

Kirzinger, Ashley, Bianca DiJulio, Bryan Wu, and Mollyann Brodie. 2017. “Kaiser Health Tracking Poll – April 2017: The Fall of the AHCA and Next Steps for the ACA.” Kaiser Family Foundation, April 4, 2016.Search in Google Scholar

Kutscher, Beth. 2015. “Kentucky hospitals gain $506 million in Medicaid expansion’s first year.” Modern Healthcare, February 12.Search in Google Scholar

Lee, Mike. 2017. “We Must Keep Our Promise to Fully Repeal Obamacare.” The Daily Signal, March 13, 2017.Search in Google Scholar

Love, Alice Ann. 1997. “Bounced in Maryland, Medicare HMO Competition Demo Again Rejected.” Daily Record (Baltimore), April 29.Search in Google Scholar

MacNeal, Caitlin. 2017. “GOP Sen. Heller Says He Won’t Vote For Obamacare Repeal Bill.” Talking Points Memo, March 17.Search in Google Scholar

Marmor, Theodore R. 2000. The Politics of Medicare. Hawthorne: Aldine De Gruyter.Search in Google Scholar

Marmor, Theodore R., and Jacob S. Hacker. 2005. “Medicare Reform and Social Insurance: The Clashes of 2003 and their Potential Fallout.” Yale Journal of Health Policy, Law, and Ethics 5: 475–489.Search in Google Scholar

Marmor, Theodore R., and Jerry L. Mashaw. 2006. “Understanding Social Insurance: Fairness, Affordability, And the ‘Modernization’ Of Social Security and Medicare.” Health Affairs 25 (3): 114–134.10.1377/hlthaff.25.w114Search in Google Scholar

Mettler, Suzanne. 2011. The Submerged State: How Invisible Government Politics Undermine American Democracy. Chicago: Chicago University Press.10.7208/chicago/9780226521664.001.0001Search in Google Scholar

Miliard, Mike. 2017. “AHA, America’s Essential Hospitals oppose GOP’s American Health Care Act.” Healthcare IT News, March 8, 2017.Search in Google Scholar

Morgan, Kimberly J., and Andrea Louise Campbell. 2011. The Delegated Welfare State: Medicare, Markets, and the Governance of Social Policy. Oxford: Oxford University Press.10.1093/acprof:oso/9780199730346.001.0001Search in Google Scholar

Needham, Michael. 2017. “GOP Plan Fails to Move Past Obamacare’s Progressive Promise.” Heritage Action for America, March 7. in Google Scholar

Oberlander, Jonathan. 2003. The Political Life of Medicare. Chicago: Chicago University Press.Search in Google Scholar

Oberlander, Jonathan. 2014. “Voucherizing Medicare.” Journal of Health Politics, Policy and Law 39 (2): 467–482.10.1215/03616878-2416348Search in Google Scholar

Oberlander, Jonathan, and R. Kent Weaver. 2015. “Unraveling from within? The Affordable Care Act and Self-Undermining Policy Feedbacks.” The Forum 13 (1): 37–62.10.1515/for-2015-0010Search in Google Scholar

Olson, Laura. 2017. “Pat Toomey Says He’s Open to ‘Smoothing’ Transition for Medicaid Changes.” The Morning Caller, May 16.Search in Google Scholar

Patashnik, Erik M. 2008. Reforms at Risk: What Happens After Major Policy Changes are Enacted. Princeton: Princeton University Press.10.1515/9781400828852Search in Google Scholar

Patashnik, Eric M., and Julian E. Zelizer. 2013. “The Struggle to Remake Politics: Liberal Reform and the Limits of Policy Feedback in the Contemporary American State.” Perspectives on Politics 11 (4): 1071–1087.10.1017/S1537592713002831Search in Google Scholar

Pear, Robert. 1999. “Deal Is Struck On Restoring Medicare Aid.” New York Times, November 11, 1999.Search in Google Scholar

Pear, Robert, and Robin Toner. 2003. “Sharply Split, House Passes Broad Medicare Overhaul.” New York Times, November 23.Search in Google Scholar

Peterson, Mark. 2015. “Third Rail of Politics: The Rise and Fall of Medicare’s Untouchability.” In Medicare and Medicaid at 50: America’s Entitlement Programs in the Age of the Affordable Care Act, edited by Alan B. Cohen, David C. Colby, Keith A. Wailoo, and Julian E. Zelizer, 147–67. New York: Oxford University Press.Search in Google Scholar

Pierson, P. 1993. “When Effect Becomes Cause: Policy Feedback and Political Change.” World Politics 45 (4): 595–628.10.2307/j.ctv1mjqv11.7Search in Google Scholar

Pierson, Paul. 2004. Politics in Time: History, Institutions, and Social Analysis. Princeton: Princeton University Press.10.1515/9781400841080Search in Google Scholar

Roper, William. 1995. Oral History Interview with Ed Berkowitz, August 29. CMS Oral History Project.Search in Google Scholar

Ryan, Paul. 2016. “Special Report with Bret Baier.” Fox News, November 10.Search in Google Scholar

Schlesinger, Mark. 2015. “Medicare and the Social Transformation of American Elders.” In Medicare and Medicaid at 50: America’s Entitlement Programs in the Age of the Affordable Care Act, edited by Alan B. Cohen, David C. Colby, Keith A. Wailoo, and Julian E. Zelizer, 119–144. New York: Oxford University Press.Search in Google Scholar

Sherfinski, David. 2017. “Rand Paul: House GOP health care plan is ‘Obamacare lite,’ ‘will not pass.’” The Washington Times, March 7.Search in Google Scholar

Siegel, Bruce. 2017. “Statement on CBO Score of American Health Care Act.” in Google Scholar

Sullivan, Peter. 2017. “GOP governors defend Medicaid Expansion.” The Hill, January 19, 2017.Search in Google Scholar

Terkel, Amanda. 2017. “Tricky Position For GOP Candidates As Health Care Repeal Heads to the Senate.” Huffington Post, May 15, 2017.Search in Google Scholar

Thompson, Frank J. 2012. Medicaid Politics: Federalism, Policy Durability, and Health Reform. Georgetown University Press, 2012.Search in Google Scholar

Tracer, Zachary and Anna Edney. 2017. “Doctors, Hospital Groups Line Up Against GOP Health Proposal.” Bloomberg, March 8.Search in Google Scholar

Trump, Donald. 2017. “Remarks by President Trump on the Health Care Bill.” The White House, Office of the Press Secretary, March 24. in Google Scholar

Tsebelis, G. 1995. “Decision Making in Political Systems: Veto Players in Presidentialism, Parliamentarism, Multicameralism and Multipartyism.” British Journal of Political Science 25 (3): 289–325.10.1017/S0007123400007225Search in Google Scholar

Weaver, Kent. 2010. “Paths and Forks or Chutes and Ladders?: Negative Feedbacks and Policy Regime Change.” Journal of Public Policy 30 (2): 137–162.10.1017/S0143814X10000061Search in Google Scholar

Young, Jeffrey. 2009. “Obama, Reid take dead aim at Medicare HMOs.” The Hill, January 14. in Google Scholar

Published Online: 2017-07-29
Published in Print: 2017-07-26

©2017 Walter de Gruyter GmbH, Berlin/Boston

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