Beland Rocco Waddan 8Béland, Daniel, Philip Rocco, and Alex Waddan. 2016.  Obamacare Wars: Federalism, State Politics, and the Affordable Care Act. Lawrence, KS: University Press of Kansas.

This book is the first monograph devoted to the politics of the Affordable Care Act’s implementation in the 50 states. Our political and comparative analysis of federalism and health care reform focuses on three major policy innovations : health-insurance exchanges, Medicaid expansion, and regulatory reform.


Praise for Obamacare Wars:

“Highly recommended” – Choice

Obamacare Wars might be the guide to policy in a new world of polarized, racialized politics where at least one of our two political parties seems not to have read classical political science about coalitions and interests.”  – Perspectives on Politics 

Obamacare Wars provides a thoughtful, well-written account of the fascinating politics associated with [the ACA’s] implementation. The book illustrates the value of a detailed empirical case study. It is an important contribution to the field of policy implementation and the politics of health policy.” – Political Science Quarterly

“Béland, Rocco, and Waddan contribute significantly to our understanding of implementation in federal systems by demonstrating convincingly that the politics and strategies of implementing this single piece of health care reform legislation in the American states were myriad and a function not only of partisan polarization but also of the diverse policy issues embedded within the law.”- The Journal of Politics

Obamacare Wars Federalism: State Politics and the Affordable Care Act provides insight into policy and program implementation of a complex and politically contentious law. (…) The strength of the work is that it takes previous theory on implementation, adds to it and applies it to the implementation of the ACA. The results help explain how and why health care reform has been unevenly enacted across the states.” – Publius: The Journal of Federalism

“The first serious analysis of a neglected but vital aspect of the Affordable Care Act, Obamacare Wars offers an informed and revealing look at the varied role of the states in the implementation of President Obama’s landmark federal health law. Ideal for both graduate and undergraduate courses, as well as law, business, and public health programs, the book should be read by anyone trying to understand the post-enactment struggles that have resulted in millions of Americans obtaining new coverage—and millions more waiting for it as their state leaders resist federal intentions.” – Jacob S. Hacker, Yale University


Journal Articles

Rocco, Philip, Andrew Kelly, and Ann Keller. 2018. “Politics at the Cutting Edge: Intergovernmental Policy Innovation in the Affordable Care Act.” Publius: The Journal of Federalism 48 (3): 425-453.

In the eight years since the passage of the Patient Protection and Affordable Care Act (ACA), state governments have remained critical sites of contention over the law. Intense partisan conflict over ACA implementation has raised questions about traditional theories of intergovernmental relations, which posit that federal-state cooperation depends largely on policy design. Yet few studies have examined how partisanship, as well as other important factors, shape state policy innovations under the ACA. This paper examines the ACA’s State Innovation Models (SIM) initiative. SIM is specifically geared towards incentivizing states to experiment with new models of payment and delivery that can improve health outcomes and/or reduce health-care costs. Drawing on a combination of quantitative and qualitative evidence, we find that states’ participation in SIM is shaped by partisanship, administrative capacity, and state policy legacies. Our findings have implications for future efforts at intergovernmental health reforms.

Béland, Daniel, Philip Rocco, and Alex Waddan. 2018. “Obamacare in the Trump Era: Where are we Now, and Where are we Going?” The Political Quarterly.

Rocco, Philip and Simon Haeder. 2018. “How Intense Policy Demanders Shape Post-Reform Politics:  Evidence from the Affordable Care Act .” Journal of Health Politics, Policy, and Law 43(2): 271-304.

The implementation of the Patient Protection and Affordable Care Act (ACA) has been a politically volatile process. The ACA’s institutional design and delayed feedback effects created a window of opportunity for its partisan opponents to launch challenges at both the federal and state level. Yet as recent research suggests, post-enactment politics depends on more than policy feedback alone. Rather, it is shaped by the partisan and interest-group environment (Weir 2006; Maltzman and Shipan 2008; Berry et al. 2010). Building on the work of Bawn et al. (2012), we argue that “intense policy demanders” played an important role in defining the policy alternatives that comprised congressional Republicans’ efforts to “repeal and replace” the ACA. To test this argument, we draw on an original dataset of bill introductions in the House of Representatives between 2011 and 2016. Our analysis suggests that business contributions and political ideology affected the likelihood that House Republicans would introduce measures repealing significant portions of the ACA. A secondary analysis shows that intense policy demanders also shaped the vote on House Republicans’ initial ACA replacement plan. These findings highlight the role intense policy demanders can play in shaping the post-reform political agenda.

Béland, Daniel, Anahely Medrano, and Philip Rocco. 2018. “Federalism and the Politics of Bottom-Up Policy Diffusion in Canada, Mexico, and the United States.” Political Science Quarterly 133 (Fall): 527–560.

Policy entrepreneurs seek to spread social policy ideas and instruments between countries, and between national and sub-national jurisdictions. Yet the literature on policy diffusion often assumes that this process occurs between structurally equivalent jurisdictions, ignoring political processes by which policy models adopted at one level of government are then transposed to another. In this article, we examine what we call bottom-up vertical diffusion between the sub-state and the national levels as it intersects with social policy. To generate hypotheses about bottom-up policy diffusion, we explore three case studies directly related to the issue of universality: the advent of near-universal health coverage in Massachusetts (Romneycare) and its impact on federal health care reform (Obamacare); the adoption of non-contributory universal pensions in Mexico City (formerly the federal district of Mexico) and its impact on Mexican federal-level social policy; finally, the creation of universal child care in Québec and its impact on Canadian social policy. The evidence suggests that bottom-up diffusion may be more likely in federal systems where policy competence is shared between national and sub-state governments and in presidential systems, which are less likely to experience a complete turnover in government control to the adversaries of a sub-state policy. The timing of bottom-up diffusion may depend on the congruence of sub-state policies with the beliefs of pivotal actors at the national level. Finally, bottom-up policy diffusion may happen more quickly when there are strong intergovernmental policy networks that act as a conduit for policy ideas.

Rocco, Philip. 2017. “The Anti-Analytic Presidency Revisited.” The Forum 15 (2): 363-378.

In his first months as president, Donald Trump has demonstrated an unprecedented aversion to expert-oriented decision making. This essay examines how Trump’s presidency exposes tensions in what Skowronek and Orren (2016) refer to as the “policy state,” especially within institutions that produce expert analyses of presidential action. While an absence of policy expertise has hamperd Trump’s agenda, his administration has also taken steps to discredit unfavorable analyses, subvert rules requiring the use of objective analysis, and construct new institutions to promote ‘alternative facts.’ By deepening public division and distrust, such activities may restructure the political environment in which the Trump presidency itself is judged.

Marian Jarlenski, Philip Rocco, Renuka Tipernini, Nivedita Gunturi, and Julie Donohue. 2017. “Making Health Policy for Low-Income Populations: An Assessment of Public Participation in a New Medicaid Waiver Process.” Journal of Health Policy, Politics, and Law 42(6): 1039-1064

Since the Supreme Court decided that the Affordable Care Act’s (ACA) Medicaid expansion is optional for the states, several have obtained federal approval to use Section 1115 waivers to expand Medicaid while changing its coverage and benefits design. There has long been concern that policy making for Medicaid populations may lack meaningful engagement with low-income constituents, and therefore the ACA established a new process under which the public can submit comments on pending Medicaid waiver applications. We analyzed 291 comment letters submitted to federal regulators pertaining to Medicaid Section 1115 waiver applications in the first five states to seek such waivers: Arkansas, Indiana, Iowa, Michigan, and Pennsylvania. We found that individual citizens, including those who identified as Medicaid-eligible, submitted a sizable majority of the comment letters. Comment letters tended to mention controversial provisions of the waivers and reflected the competing political rhetoric of “personal responsibility” versus “vulnerable populations.” Despite the fact that the federal government seemed likely to approve the waiver applications, we found robust public engagement, reflecting the salience of the issue of Medicaid expansion under the ACA. Our findings are consistent with the argument that Medicaid is a program of growing centrality in US health politics.

Rocco, Philip. 2017. “Informal Caregiving and the Politics of Policy Drift.” Journal of Aging and Social Policy  29(5): 413-432.

Informal caregivers play an increasingly important role in caring for aging Americans. Yet existing social policies that could support informal caregiving have experienced “policy drift,” a failure to adapt to social risks that develop after policies are initially enacted. This article examines policymakers’ success at updating seven major policies to address caregiver needs. It draws on an original dataset of legislation in this area introduced between 1991 and 2006 (n=96). Findings indicate that drift is more likely when policy updates are costly, lack support from members of majority parties in the House and Senate, and fail to generate bipartisan support.

Rocco, Philip (Lead Author), Andrew S. Kelly, Daniel Béland, and Michael Kinane. 2017. “The New Politics of US Health Care Prices: Institutional Reconfiguration and the Emergence of All-Payer Claims Databases.” Journal of Health Policy, Politics, and Law 42(1):5-52.

Prices are a significant driver of health care cost in the United States. Existing research on the politics of health-system reform has emphasized the limited nature of policy entrepreneurs’ efforts at solving the problem of rising prices through direct regulation at the state level. Yet this literature fails to account for how change agents in the states gradually reconfigured the politics of prices, forging new, transparency-based policy instruments called All-Payer Claims Databases (APCDs), which are designed to empower consumers, purchasers, and states to make informed market and policy choices. This article advances a pragmatic institutionalist account of how APCDs emerged as the dominant model for reforming healthcare prices, which emphasizes the role of creative action by agents of change. While APCD advocates faced significant institutional barriers to policy change, we show how they reconfigured existing ideas, tactical repertoires, and legal-technical infrastructures to develop a politically and technologically robust reform. Our analysis has important implications for theories of how change agents overcome structural barriers to health reform.

Béland, Daniel, Philip Rocco, and Alex Waddan. 2016. “Obamacare and the Politics of Universal Health Insurance Coverage in the United States.” Social Policy & Administration 50 (4): 428-451.

In the United States, universal coverage has long been a key objective of liberal reformers. Yet, despite the enactment of the Patient Protection and Affordable Care Act (PPACA) in 2010, the United States is not set to provide health care coverage to all, even if and when that reform is fully implemented. This article explores this issue by asking the following question: why was a clear commitment to universal coverage, the norm in other industrialized countries, excluded as a core objective of the PPACA and how has post-enactment politics at both the federal and the state level further shaped coverage issues? The analysis traces the issue of universal coverage prior to the debate over the PPACA, during the 2008 presidential race, and during consideration of the bill. The article then looks at the post-enactment politics of coverage, with a particular focus on how states have responded to the planned use of the Medicaid programme to expand access to care. The article concludes by discussing how an explanation of the limits of the PPACA, in terms of both its commitment to universal coverage and, more importantly, the failure to provide comprehensive health insurance to all, requires an understanding of complex institutional and policy dynamics.

Béland, Daniel, Philip Rocco, and Alex Waddan. 2016. “Reassessing Policy Drift: Social Policy Change in the United States.” Social Policy & Administration 50(2): 201-218.

As formulated by Jacob Hacker, the concept of policy drift turned institutional theories of public policy on their heads by suggesting that consequential policy changes often happen in the absence of reform. Especially prevalent in times of political gridlock or stasis, policy drift is a useful concept for capturing how inaction can gradually diminish the effectiveness of social programs over time. By highlighting cases of difficult-to-see policy inaction, however, Hacker’s concept sets a high bar for empirical scholarship. In this article, we suggest that analysing policy drift requires attention to comparative policy outcomes, the implementation of reforms intended to alleviate drift, and the time frame of the study. With these insights in mind, we analyse the impact of drift on US retirement security and health care coverage to reflect policy changes that have occurred since Hacker’s original analysis was published.

Rocco, Philip, Walid F. Gellad, Julie M. Donohue. 2015. “Modernizing Medicaid Managed Care: Can States Meet the Data Challenges?JAMA 314(15): 1559-1560.

This short article discusses implementation challenges related to the Center for Medicare and Medicaid Services’ proposed overhaul of Medicaid’s managed care programs.

Béland, Daniel, Philip Rocco and Alex Waddan. 2015. “Polarized Stakeholders and Institutional Vulnerabilities: The Enduring Politics of the Affordable Care Act.”  Clinical Therapeutics  37 (4): 720–726.

Making the Affordable Care Act (ACA) function depends crucially on stakeholders such as hospital associations, pharmaceutical companies, and private insurance providers. It is not merely health care stakeholders that will influence the ACA’s outcomes, however. This article argues that political actors, particularly elected officials, play leading parts, though they do not always share the incentives and preferences of other stakeholders. In particular, partisan and ideological opponents of the ACA have sought to obstruct the implementation of the reform at the state level rather than negotiate how best to put it into practice. Drawing on publicly-available data, government documents, news reports, and interviews conducted by one of the co-authors, we show that their success hinges critically on several institutional vulnerabilities that vary across three major reform streams within the ACA: health insurance exchanges (or marketplaces, as they are currently known), the proposed expansion in Medicaid coverage and, finally, regulatory reform.

Tummers, Lars and Philip Rocco. 2015. “Serving Clients When the Server Crashes: How Frontline Workers Cope With E-Government Challenges.Public Administration Review 75(6): 817-827.

Public service delivery in the contemporary American state is becoming increasingly challenging. E-government policies place high technical and cognitive demands on agencies and citizens in an environment of budget austerity and political polarization. While governments implementing these policies often mobilize frontline workers to assist citizens, we know little about how they cope with such challenging circumstances. This article fills this gap by examining frontline workers (e.g. navigators and assisters) implementing the Patient Protection and Affordable Care Act (ACA). Based on interviews, member checks, and document analyses, we conclude that frontline workers coped by “moving towards clients”: they bend rules, learn about problems and collaborate with colleagues to help clients. They were far less inclined to “move away” or “against” clients, for instance, via rationing or rigid rule following. Our evidence suggests that frontline workers can play a vital role in delivering e-government policies, even under adverse conditions.

–A Public Administration Review podcast summarizing this article can be found here; a commentary on the article by Sally McCarty can be found here.

Rocco, Philip. 2015. “Making Federalism Work? The Politics of Intergovernmental Collaboration and the PPACA.Journal of Health and Human Services Administration 37(4): 412–461.

The Patient Protection and Affordable Care Act (PPACA) is a complex piece of legislation that requires a high level of collaboration between actors at multiple levels of government, federal and state, to successfully implement its provisions. However, the polarized political environment in which the law was passed has created roadblocks for implementation, with Republican governors claiming that they will not negotiate with federal agencies over many of the law’s key details. This paper reports on the results of a recent survey of state-level administrators that examines the extent of state-federal collaboration to implement health reform. I find that state administrators’ engagement in collaborative activity is generally robust. Even so, state administrators’ perceptions of their relationship with federal agents appear to be strongly related to the partisan compositions of their states, suggesting that political conflict over the reform may still pose dilemmas for future implementation efforts.

Béland, Daniel, Philip Rocco, and Alex Waddan. 2014. “Implementing Health Care Reform in the United States: Intergovernmental Politics and the Dilemmas of Institutional Design.Health Policy 116(1): 51–60.

The Affordable Care Act (ACA) was enacted, and continues to operate, under conditions of political polarization. In this article, we argue that the law’s intergovernmental structure has amplified political conflict over its implementation by distributing governing authority to political actors at both levels of the American federal system. We review the ways in which the law’s demands for institutional coordination between federal and state governments (and especially the role it preserves for governors and state legislatures) have created difficulties for rolling out health-insurance exchanges and expanding the Medicaid program. By contrast, we show how the institutional design of the ACA’s regulatory reforms of the insurance market, which diminish the reform’s political salience, have allowed for considerably less friction during the implementation process. This article thus highlights the implications of multi-level institutional designs for the post-enactment politics of major reforms.

Béland, Daniel, Philip Rocco, and Alex Waddan. 2014. “Obamacare, Universal Credit, and the Trilemma of Public Services.” Public Administration Review 74 (2): 142–143.

Critiques of “inefficient bureaucracy” are a hallmark of Anglo-American political culture, so it comes as no surprise that politicians and journalists have recently been at full volume when chastising “disastrous” technological fouls both in the rollout of Obamacare (the Patient Protection and Affordable Care Act) and in the implementation of Universal Credit, a technologically complex U.K. welfare reform, which has exhibited many of Obamacare’s symptoms. While this focus on ineptitude is understandable when government fails, it hides a constellation of challenges to effective public service delivery. In this essay, we argue that contemporary public-service challenges constitute a “trilemma” in which the mix of increasing demands for public services, austerity, and a culture of “high-stakes” accountability has made the governance of public policies increasingly prone to critical system failures.

Rocco, Philip and Chloe Thurston. 2014. “From Metaphors to Measures: Observable Indicators of Gradual Institutional Change.Journal of Public Policy 34 (1): 35–62.

A range of scholarship on social policy has recently emphasized the importance of gradual processes of institutional change (Mahoney and Thelen 2010, Faletti and Lynch 2009). However, conceptual work on the identification of processes such as drift, conversion, and layering has not produced clear empirical indicators that distinguish these processes from one another. We argue that in order to improve the validity of its empirical findings, scholarship on gradual change should – and can – pay more attention to issues of measurement and detection. We contribute to this goal by clearly articulating evidentiary standards for mechanisms of gradual institutional change and validating these standards against extant empirical work on political economy. (Blogged at The Monkey Cage How Patronage Politics Ate the Port Authority 1/13/14)

Chatfield, Sara and Philip Rocco. 2014. “Is Federalism a Political Safety Valve? Evidence from Congressional Decision-Making, 1960–2005.Publius: The Journal of Federalism 44 (1): 1-23.

American federalism is often described as a system that contains “political safety valves”, or institutional mechanisms that ensure that major policy reforms can be created, even during periods of intense political conflict. By granting discretion to the states, for example, scholars claim that Congress can ensure that diverse constituencies receive their preferred policies. In this article, we examine Congress’s pattern of delegating discretion to sub-national institutions in the postwar period, systematically assessing how the political conditions under which a broad sample of landmark legislation passed are related to the delegation of administrative authority to the states. Contrary to the “safety valve” image of federalism, we find very little evidence to suggest that Congress grants more discretion to sub-national governments under periods of intense political conflict.

Rocco, Philip. 2011. “Wissensproduktion in der RAND Corporation.” Macht und Geist im Kalten Krieg. Edited by Bernd Greiner, Tim B. Müller, and Claudia Weber. Hamburg: Hamburger Institut für Sozialforschung. 301320.

In this essay, I claim that ideas and analytical traditions that emerged from the cold war, especially of a particularly policy-relevant nature, owe their contours to the political and social dynamics of the groups that produced them. In particular, I argue that the privatized nature of the American cold-war state had a substantial effect on the analytical techniques of researchers at the RAND Corporation, the birthplace of late-twentieth-century policy science. RAND’s management, I argue, desired to be perceived as legitimate by state agencies which the Corporation advised, academic departments at universities which generated its work force, as well as peer research organizations with which it collaborated. Oral histories of RAND’s institutionalization suggest that ideas and analytical approaches cultivated within the organization’s walls can be seen as attempts, however incomplete, at creating such a credible institutional image. I conclude by highlighting the broader implications of the contract-centered nature of the cold-war state for the history of the policy sciences.