Volume 13, Issue 1

Social Security will be insolvent in 2033. If nothing is done, retirees will face an immediate 23% cut in their monthly benefits. The solvency cliff and its approximate date have been known for more than two decades. This paper examines why Congress has avoided fixing Social Security when the solutions were relatively affordable and when the baby-boom generation could have helped pay its share of the costs. It also examines what solutions will become politically feasible once the solvency cliff arrives. The surprise is that raising the wage base – in short, taxing the affluent – becomes the most politically appealing fix when insolvency arrives, despite the fact that this solution has no political appeal absent a crisis. Politics at the precipice is very different from ordinary politics.

Social Security is widely known as “The Third Rail of American Politics” and the program has proved been remarkably stable and politically resilient, over time. While true, this basic story about the institutional stability of Social Security in the US should not hide the segmented, discontinuous nature of its politics over the last four decades. As suggested in this article, the changing nature of Social Security politics is reflected in the variety of the policy options debated, which range from incremental benefit cuts and revenue increases adopted during the Carter and the Reagan years to structural, path-shifting proposals associated with the idea of Social Security privatization, which only became a mainstream policy alternative during the Clinton years. The following analysis explores the debate about these diverse policy alternatives, if and when they entered the federal policy agenda during the periods under consideration.

The 2010 Patient Protection and Affordable Care Act (ACA) passed through Congress on partisan lines and with only lukewarm public support. The Obama administration and Congressional Democrats, though, had reason to expect that the ACA’s political fortunes would substantially improve as the acrimonious debate over its enactment faded and millions of Americans came to receive significant benefits from health care reform. But 5 years after its passage, the ACA’s political foundations remain shaky. We suggest that one reason for the ACA’s unsettled fate is the role of policy feedbacks that undermine public support for and opponents’ acceptance of the program. The ACA experience highlights how policy feedbacks can vary widely in their political impact, and suggests that some policies are in fact self-undermining. We also emphasize the crucial role of partisan polarization as a mediating factor in shaping policy feedbacks.

As the list of Republican-led states participating in the Medicaid expansion grows, it is becoming increasingly clear that partisanship and ideology alone cannot fully explain states’ choices. This paper examines the political and practical dynamics influencing state Medicaid expansion decisions. Whereas resources and history have served to reinforce the effects of partisanship and ideology, several countervailing forces – including public opinion, interest group pressure, budgetary considerations, and need – are pushing even the reddest states toward expansion. The relative force of these competing pressures within a state can help explain not only whether or not the state expands Medicaid, but also the manner in which it does so, such as through a waiver or executive action. I present five case studies – Nevada, Arizona, Ohio, Arkansas, and Tennessee – to illustrate how these various dynamics are shaping states’ decisions.

Long-term care is a serious but largely unrecognized problem in the US. The CLASS Act was a new program embedded within the Affordable Care Act that was supposed to bring relief to disabled individuals and Medicaid, the primary payer for long-term care. However, the program had an unworkable design, and it was eventually abandoned by the Obama administration. CLASS’ flaws were largely the product of a policy area in which ignorance and misinformation render any effective and fiscally sound program politically unfeasible. As such, the rise and fall of the CLASS Act highlights the profound challenges facing any attempt to pass serious long-term care reform and underscores the need to raise awareness of America’s long-term care challenge.

A family tragedy enables a social policy scholar to examine how American social assistance works from the recipient perspective. The experience results in a reexamination of conventional wisdom around US social policy. In contrast to the revisionist account, meager social assistance programs are still pretty meager. Despite the bifurcation between deserving and undeserving beneficiaries, some deserving populations are swept into catch-all means-tested programs and fare badly. Finally, the experience forces a new look at research approaches to social policy. More qualitative and ethnographic work is needed, as well as examinations of the interactions among multiple programs and their complicated and often contradictory rules.

The private sphere has always been an important component in US healthcare entitlements. Since the ACA further embeds the role of private actors, how private actors make claims on the state, and how the state reacts to these claims, becomes even more important, because such claims significantly shape US healthcare entitlements. The extent and increase of private benefits and contracting with private health plans is explicated for each healthcare entitlement program. The politics of how private inclusion shapes healthcare entitlements is examined with three main implications: it (1) creates a dominant discourse of health care deficits and spending crises; (2) submerges the role of government and may diminish mobilization for claiming entitlements; and (3) reduces equity in the distribution of costs and benefits. I conclude by highlighting that there are simple policy designs to address these problems, but the political dynamics of private inclusion will likely work against such policy logics.

In 2009, Medicare Advantage became a prime target in the Obama Administration’s efforts to pay for the Affordable Care Act (ACA). After securing substantial cuts to a program the President described as a failure, the Obama administration was compelled to take unprecedented administrative steps to put billions of dollars back into Medicare Advantage. These developments demonstrate how Medicare Advantage’s support constituency, which has come to include Democrats, Republicans, beneficiaries, and the managed care industry, has maintained more political influence in the aftermath of the ACA than some initially believed. The continued and growing influence of the Medicare Advantage constituency does not, however, mean that Medicare is primed for a more conservative turn toward vouchers or premium support. With the provision of generous benefits and increasing evidence that Medicare Advantage produces higher quality health outcomes than traditional Medicare, Medicare Advantage appears to be secure in its current form.

This essay examines how Martha Derthick creatively combined history and political science to produce influential analyses of key public programs, such as Social Security.

Martha Derthick, one of the nation’s foremost scholars of federalism and public administration, died on January 12. Gareth Davies, one of her former students, reflects here on her intellectual legacy, especially as reflected in her publications, but also, more briefly, on her approach to mentoring.