THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010: THE VICTORY OF “UNORTHODOX LAWMAKING” – A STUDY OF THE AMERICAN HEALTH CARE REFORM.

In the course of the evening of March 2010, the US Congress passed a comprehensive reform of the American health care system, aimed at encouraging the development of a universal health care coverage by relying on the private market of health insurance, and encouraging managed competition mechanisms among private insurance companies. When looking at the one year long process for reform, what strikes an observer of US Health care policy in the first place is precisely fact that the democratic majority was able to enact something in a political field characterized by strong resistance to change (Pierson, 1994). The need for health care reform has been known and recognized by American politicians all along the 20th century, with several attempts to overhaul health care policy in past decades. Until 2010 however, these broad reform projects have all failed somewhere between interest group mobilization and factional conflicts among parties in Congress (Steinmo and Watts, 1995, Hacker, 2002). Confronted with such systematic failures, the “deadlock” hypothesis gradually became commonplace among American health care policy analysis. In 2009-2010, the academic community expected the scenario to repeat again and the reform to be killed under the assaults of hostile interest groups or after rifts between democrats and republicans. From this perspective, studying the politics surrounding the process of this reform appear of interest, for several reasons. First of all, it represents a visible case of a reform reinforcing the American welfare state in what has been called the “era of permanent austerity” (Pierson, 2001). Domestic economic tensions (such as public deficits, high levels of unemployment, increasing fiscal pressures on government) as well as a longstanding trend toward neoliberal reforms would more likely lead to expect welfare retrenchment reforms or re-commodification reforms (Esping- Andersen, 1999; Pierson, 2001). The 2010 reform, which aims to expand the coverage to every American citizen or resident, is consequently striking. It tells us and is an occasion to ask what kind of reform can be enacted in the context of the New Politics of the Welfare State. Indeed, since the reform was introduced in a time of permanent austerity, implying radically different logics than the logics of Welfare expansion (Pierson, 2001) and more painful choices for policy-makers, antinomic or paradoxical goals had to coexist in the reform. Especially, and this was already the case in Clinton’s proposal, the reform had to conceal dual - and opposite – goals of expanding coverage to nearly cover all Americans, but in the same time restricting the costs of the system. Those two objectives, characterizing the new politics of Health care in the US (Hacker, Sckopol, 1997), as well as the question of how to combine them, hardly find consensual options among policy makers and harden the burden on every reform attempt. The approach followed here argues for a careful and qualitative consideration of the political process of the reform, of the coalitions of actors involved and of the constraints they faced to achieve their project as necessary to understand the conditions of change and overcome the very notion of gridlock that long characterized US health care analysis. Adopting a new-institutionnalism approach centered on actors (Scharpf, 1997, Mayntz, Scharpf, 2001), I suggest an interpretation of the reform process focusing on interactions between major political players, ideas they supported, the strategies they adopted to overcome the multiple institutional constraints of the US policymaking process. Based on qualitative materials made of approximately 100 semi-directed interviews realized at different stages of the reform process – from august 2008 to may 2010 –. I argue that the democratic majority, building on lessons from both Clinton’s failed attempt at reforming health care in the mid-1990 and from the republicans’ subsequent strategies of using strong congressional leadership to pass social reforms, was able to overcome institutional constraints that have long prevented comprehensive change. Agreeing at the end of the day to accept more conservative options (they moved to the right), the 2010 Democrats capitalized on increased partisan control of the legislative process in Congress and increased cohesion among their members. A more centralized legislative process, which has been described as “unorthodox lawmaking” (Sinclair, 2007), enabled the Democratic leadership to overcome multiple institutional and political veto players (Tsebelis, 2002) characterizing the policymaking process in the US. Increased partisanship, far from paralyzing the reform process, reinforced the Democratic Party’s capacities, while gathering a large and heterogeneous majority, to act as a coherent actor and enact large-scale reform in a highly conflictual policy sector.