The Patient Protection and Affordable Care Act (ACA): From Clinton’s Failure to Obama’s Success to Trump’s Failure to “Repeal and Replace” the ACA A classic example of agenda setting, punctuated equilibrium, and path dependency is the Affordable Care Act (ACA).

 Group 2. Read case study 3-3 in your textbook (pp. 69-70). Explain how the Kingdon Model, Punctuated Equilibrium, and/or Path Dependency were involved in the passage of the Affordable Care Act.

CASE STUDY 3-3: The Patient Protection and Affordable Care Act (ACA): From Clinton’s
Failure to Obama’s Success to Trump’s Failure to “Repeal and Replace” the ACA
A classic example of agenda setting, punctuated equilibrium, and path dependency is the
Affordable Care Act (ACA). The passage of the ACA in March 2010 was a remarkable policy
breakthrough that achieved long-sought expansions of health insurance coverage and
strengthened insurance regulations (e.g., forbidding exclusions for preexisting conditions and
allowing dependents to stay on their parents’ health plans until age 26). The ACA’s roots,
however, lie in the failed efforts of Democrats’ and President Clinton’s efforts at comprehensive
Milstead’s Health Policy and Politics: A Nurse’s Guide, Seventh Edition
Nancy M. Short
Case Study
Copyright © 2022 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
healthcare reform in 1993–1994.
In both 1992–1993 and 2009–2010, policy windows for health reform opened due to the
convergence of problem, policy, and political streams in the form of the national elections of
1992 and 2008 that punctuated long-existing policy equilibriums. In both instances, long-running
problems with millions of uninsured Americans collided with the ending of 8 years of
Republican control of the White House. This collision created a new and rare political agenda
that permitted consideration of major health policy changes (Cammisa & Manuel, 2013).
What limited both Clinton’s and Obama’s efforts at significant healthcare reform, however,
was path dependency. All the institutions, programs (Medicare, Medicaid), policy traditions
(employer-provided health insurance), tax legacies (the tax exemption of employer-provided
health insurance), and more that have built up over decades constrain and limit the ability to
dramatically change the healthcare system. Clinton tried to ignore the resistance of path
dependency and failed; Obama and Democrats in Congress in 2009–2010 learned from Clinton’s
1993–1994 failure and modified the ACA proposal according to the constraints imposed by path
dependency (Oberlander, 2010).
As Paul Starr, Princeton University sociologist and recipient of the Pulitzer Prize for his
seminal history of the medical profession in The Social Transformation of American Medicine
(2017), explains, Obama benefited from a reform consensus that had emerged in the years
leading up to Obama’s election to the presidency in 2009. The Clinton plan was far more
ambitious than Obama’s Affordable Care Act, particularly on cost containment. The ACA was
also less threatening to the healthcare industry. By 2009, Democrats had coalesced around a path
dependency reform model of the Massachusetts strategy—expanding Medicaid, subsidizing
private coverage in limited insurance exchanges, and backing it up with a (weak) individual
mandate (Starr, 2013). With a more unified Democratic Party and more interest group support
than Clinton had in 1993–1994, Obama was able to succeed in getting legislation passed and
implemented (Starr, 2017). At the same time, the ACA’s impact has been far more limited
compared to what Clinton proposed in 1993 because of the limits of path dependency. Not a
single Republican voted for the ACA in either house of Congress. Democrats could only pass a
more modest, incremental policy of health reform due to the institutional, economic, and political
constraints that path dependency imposes in a governmental system that is defined by intense
Milstead’s Health Policy and Politics: A Nurse’s Guide, Seventh Edition
Nancy M. Short
Case Study
Copyright © 2022 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
checks and balances and extensive fragmentation of political power (Hacker, 2010).
Ironically, the path dependency limits that Obama faced in successfully passing modest
healthcare reform with the ACA also limited President Trump’s and Republicans’ efforts to
“repeal and replace” the ACA during the Trump administration (Hacker & Pierson, 2018). Even
their attempts to reduce Medicaid eligibility for low-income individuals failed due to the
resiliency inherent in path dependency, where institutions and programs in place for just a few
years can survive concerted efforts to destroy them (Rosenbaum, 2018). The ACA’s path-
dependent survival is a testament “to its particular balance and timing of benefits and costs being
shielded long enough by election results and the constitutional separation of powers to have its
benefits take root” (Peterson, 2018, p. 605). In this sense, the ACA’s resiliency has come to
resemble that of Social Security, Medicare, and Medicaid, providing valuable benefits to
millions of American beneficiaries and healthcare providers (Peterson, 2020).