Publications by authors named "Lawrence R Jacobs"

The passage and initial implementation of the Affordable Care Act (ACA) were imperiled by partisan divisions, court challenges, and the quagmire of federalism. In the aftermath of Republican efforts to repeal the ACA, however, the law not only carries on but also is changing the nature of political debate as its benefits are facilitating increased support for it, creating new constituents who rely on its benefits and share intense attachments to them, and lifting the confidence of Americans in both their individual competence to participate effectively in politics and that government will respond. Critics from the Left and the Right differ on their favored remedy, but both have failed to appreciate the qualitative shifts brought on by the ACA; this myopia results from viewing reform as a fixed endpoint instead of a process of evolution over time.

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The Affordable Care Act (ACA) was enacted in a deeply polarized context, and it has endured multiple challenges to its implementation and its very existence that continue to this day. Yet, we find that the law is entering a new phase of acceptance among the American public, such that it presents political risks to politicians who would dare to weaken it. We have conducted a panel study of Americans' public opinion on the ACA since 2010, returning to the same respondents every two years to ask the same questions.

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Against a backdrop of ongoing operational challenges, insurance market turbulence, and the ever present pull of partisanship, enrollment in the ACA's programs has soared and significant variations have developed across states in terms of their pace of coverage expansion. Our article explores why ACA enrollment has varied so dramatically across states. We explore the potential influence of party control, presidential cueing, administrative capacity, the reverberating effects of ACA policy decisions, affluence, and unemployment on enrollment.

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Six years after the Affordable Care Act (ACA) became law, the number of nonelderly Americans with health insurance has expanded by twenty million, and the uninsurance rate has declined nearly 9 percentage points. Nevertheless, public opinion about the law remains deeply divided. We investigated how individuals may be experiencing and responding to health reform implementation by analyzing three waves of a panel study we conducted in 2010, 2012, and 2014.

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Objectives: We examined the potential economic, policy, and political influences on the decisions of the 50 US states to expand Medicaid under the Affordable Care Act.

Methods: We related a measure of relative state progress toward Medicaid expansion updated to 2015 to each state's economic circumstances, established policy frameworks in states, partisan control of state government, and lobbyists for businesses, medical professionals, unions, and public interest organizations.

Results: The 9201 lobbyists working on health care reform in state capitols exerted a strong and significant impact on Medicaid expansion.

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After the passage of the Patient Protection and Affordable Care Act in March 2010 and the affirmation of its constitutionality by the Supreme Court in 2012, key decisions about the implementation of health care reform are now in the hands of states. But our understanding of these decisions is hampered by simplistic sortings of state directions into two or three simple, rigid categories. This article takes a different approach--it tracks the variations in relative state progress in implementing Medicaid expansion across a continuum of activities and steps in the decision-making process.

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Pitched battles over aspects of the law will continue, but the fundamental reality is that stakeholders are fully engaged, and implementation will move ahead.

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In the aftermath of the Supreme Court decision largely upholding the constitutionality of the Affordable Care Act, many stakeholders have renewed their commitment to health care reform. In fact, a new political economy of health care has emerged that is characterized by three dynamics. One is the "log-rolling" dynamic of distributive politics, as evident in mutually supportive efforts for maintenance and expansion of subsidies and other opportunities to advance the interests of stakeholders.

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Research on stasis or change in public opinion toward health, health policy, and medical care tends to focus on short-term dynamics and to emphasize the impact of discrete messages communicated by individual speakers in particular situations. This focus on what we term "situational framing," though valuable in some respects, is poorly equipped to assess changes that may occur over the longer term. We focus, instead, on "structural framing" to understand how institutionalized public health and health care policies impact public opinion and behavior over time.

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The most significant health reform in American history was the passage of Medicare in 1965, but this was an accomplishment born of defeat. Medicare was designed and understood by its early promoters as an approach to health reform, not simply as a discrete program for a distinct target population. Although Medicare incrementalism has tended to be shunted aside when the opportunities for health reform are most promising, the final years of the Johnson administration reveal previously underappreciated efforts to expand Medicare eligibility to large new population groups and offer insights into the continuing potential of Medicare incrementalism in our own time.

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