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AbstractIn 2019, nearly 70 percent of Medicaid beneficiaries received their health insurance coverage through a private, managed care organization (MCO). Twenty-five years earlier, 9.5 percent of Medicaid beneficiaries were enrolled in MCOs. This dramatic growth in Medicaid managed care enrollment represents the delegation of significant power by federal and state governments over a critical social program to private actors and market forces. Medicare, too, experienced a similar pattern of transformation. Together, Medicaid and Medicare, two critical pillars of American social policy, paid more than half a trillion dollars to private insurance companies in 2019 to provide public health insurance to 75 million people. This manuscript examines the policy consequences of building private firms directly into the structure of American social policies. In contrast to existing work on "submerged" or "delegated" policies, this manuscript highlights the structural power that such policies bestow on the government's private partners and develops a new theory of structural power in which firms are able to constrain health policy reform through their threats to disrupt the delivery of public policies and social benefits to millions of people across the United States.

Donald J. Trump's unexpected victory in the 2016 presidential election cast a long shadow over the American welfare state. With continued Republican control of the House and Senate, Trump's occupancy of the Oval Office removed a critical constraint on Republican efforts to dismantle key Democratic social policy achievements—both old and new. Despite the absence of these important institutional veto-points, the policies that were first identified and targeted by Republicans during the Trump era have proved to be more robust than many observers and policymakers initially believed. By applying the theoretical insights and methodological tools of American Political Development, this article explores how long-running policy processes have altered the political landscape in often underappreciated ways to narrow the prospects for large-scale policy reform. More specifically, this article examines the political dynamics of Medicare and the Affordable Care Act in the early days of the Trump administration. The pressures exerted on both programs by an unpredictable president and unified Republican control of Congress provides a unique opportunity to differentiate between and assess the prospects for policy sustainability and policy stability.

AbstractIn 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.

When well directed, science is the greatest agency for the welfare of mankind. John Wesley Powell, the director of the United States Geological Survey (USGS), delivered this message to Congress in 1884. The purpose of Powell's testimony to Congress was not to argue for the erection of an organizational framework for American science, but to defend the one that had been put in place decades earlier. At the time of Powell's testimony, the United States had already begun to assume the mantle of the greatest scientific nation on the planet. "I have studied the question closely," declared W. H. Smyth, the president of the Royal Geographical Society of London, "and do not hesitate to pronounce the conviction that though the Americans were last in the field, they have, per saltum, leaped into the very front of the rank." The organizational structure at the heart of America's rapid scientific rise was initially constructed by scientists serving in the nineteenth-century American bureaucracy—by men like John W. Powell. Often seen as a source of stateincapacity, in this instance, the federal bureaucracy was the most important force in American scientific development.

Facing fragmented institutions and partisan polarization, officials in the United States often attempt to engineer policy change without assembling new legislative majorities. To this end, they have increasingly employed demonstration projects, policy innovations undertaken by administrative agencies designed to test alternative approaches to implementation or service delivery on a limited segment of the target population and for a limited period of time. Despite the increasing importance of demonstration projects, they are an undertheorized source of policy change. In this article, we conceptualize demonstration projects as part of a class of experimental institutions that, while incremental in scope, have the potential to 'scale up' into more substantial reforms. Data from three Medicare demonstrations suggest that policy change is more likely when programmes generate strong support constituencies; minimize administrative and infrastructural costs; are undertaken in contexts with few veto points; and align with the time horizons of elected officials.