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The policy feedback literature developed in an era in which the level of polarization and the intensity of party competition were far lower than today. These background conditions narrowed the scope of many policy debates and facilitated the consolidation of programmatic expansions after their enactment. As a result, the feedback literature emphasized the ways that new policies build supportive constituencies and become entrenched. While the core insight that policies can generate major political repercussions remains solid, American political development (APD) scholars should pay greater attention to the role of negative feedback processes and backlash politics in an era of disunity. Based on a review of New York Times articles mentioning policy backlash between 1960 and 2019, I show that the 2010s was a period of heightened countermobilization. Backlash forces have diffused from civil rights into many other arenas—including health, trade, and immigration—due to partisan polarization, conflicts over cultural shifts, and the negative feedback from activist government itself.

Policy backlash occurs when people or organizations mobilize against a policy during or after its enactment, diminishing the power of supporters and reducing the likelihood of the policy’s subsequent entrenchment and expansion. This article analyzes backlash as a case of negative policy feedback and explores some of the mechanisms through which backlash occurs among elites, organized groups, and mass publics. The main focus is on the politics of “backlash prevention”: using strategies to minimize the prospects of countercoalitions against policies serving diffuse or marginalized constituencies in an era of partisan polarization. These strategies include increasing the progressivity of programs after they have become embedded, recognizing that reforms can threaten the social identities and status of constituencies, and increasing reliance on low-visibility taxes. While countercoalitions cannot be completely neutralized in today’s contentious political environment, these strategies can load the dice in favor of sustainable change.

This chapter discusses the results of national public opinion surveys that illuminate how ordinary citizens think about the medical evidence problem. The surveys demonstrate that doctors possess the influence, prestige, and standing to play a leadership role in educating the public about the inefficiencies and waste of the U.S. health care system. Because most Americans believe “doctor knows best,” they tend to have confidence in the advice of doctors, not only about individual medical problems, but also about broader health care reform issues. The surveys also reveal that Americans are naturally wary of health care reform proposals they fear could constrain physician discretion, such as requiring doctors to follow evidence-based clinical guidelines. The public's anxieties about proposals to make medicine more evidence based, however, can be overcome. Physician endorsements of such reforms significantly alleviate public fears. The survey results suggest that if doctors were to become forceful advocates for reform, their reputations as trusted, well-motivated experts position them to shape the views of ordinary citizens.

This chapter defines the “medical guesswork” problem and explains how the poor integration of evidence into clinical decision making harms the performance of the health care sector. The lack of an effective and politically sustainable response to the medical evidence problem—and this is a sad indictment of the U.S. political system—would be somewhat less surprising if the medical evidence problem harmed “only” politically marginalized groups, such as the poor. But all Americans, including wealthy patients covered by generous insurance plans, suffer if doctors do not follow best practices or if evidence does not exist about, for example, the best way to treat prostate cancer or back pain. The pathologies of the U.S. medical system thus cannot be attributed to distributional bias in an otherwise high-performance system. These inefficiencies and performance breakdowns are widespread and systemic.

This chapter explores the institutional roots of medical professionalism in the United States. It examines why the U.S. health care system delegates therapeutic authority to individual doctors and medical societies, with little centralized oversight in programs like Medicare. The chapter also presents findings from a national survey of physicians to gauge their views on the proper role of medical societies in medical evidence controversies. Although the tradition of professional autonomy places the physician at the center of the U.S. health care system, the survey evidence suggests that physicians do not recognize the important role their own beliefs (and potential misconceptions) about what constitutes good medical practice play in contributing to the problems of overutilization and inefficiency. The survey also reveals that doctors generally want their medical societies to forcefully defend treatments challenged by research. At the same time, the survey uncovers notable differences among the views of physicians based on both their medical specialization and partisan affiliation. Doctors who identify with the Republican Party place a somewhat higher priority on protecting clinical autonomy (and a somewhat lower priority on discouraging clinical interventions with minor or no benefits) than do doctors who identify with the Democratic Party.

This introductory chapter explains why evidence-based medicine is important. The sluggish incorporation of medical evidence into clinical practice is a concern for three key reasons: safety, quality, and the efficiency of resource allocation. First, the delivery of unproven care can expose patients to serious risks. Second, the slow integration of evidence can lead to suboptimal outcomes for patients who receive treatments that work less well for their conditions than alternatives. Third, the failure to implement evidence-based practices encourages wasteful spending, causing the health care system to underperform relative to its level of investment. This book assesses whether the delivery of medical care in the United States is evidence based. It argues that by systematically ignoring scientific evidence (or the lack thereof), the United States is substantially out of balance.

This chapter focuses on the evidence-based medicine (EBM) reform project. Ultimately, if the EBM project is to realize its aspirational goal to improve the quality and efficiency of U.S. medical care, it is necessary but insufficient for research agencies like Patient-Centered Outcomes Research Institute (PCORI) to endure. In the long run, patterns of medical governance must change. PCORI (or whatever entity succeeds it) must develop a reputation among key stakeholders for competence, relevance, and impact that causes policy makers to conclude that supporting EBM is in their own political interest. The chapter then draws on lessons from the literature on U.S. state building to develop strategies to increase the durability of medical governance reform in contemporary American politics. It also briefly reviews the challenges of political sustainability that face any new agency or policy.

This chapter evaluates the politics of the Obama administration's effort to promote comparative effectiveness research (CER) as the scientific foundation of health care quality improvements and cost control. It argues that elite polarization and a near parity of partisan competition degrades government problem solving in two ways. First, it creates incentives for politicians to transform what plausibly could be consensual “valence” issues, on which nearly all candidates and parties adopt the same stance, into contentious “position” issues, on which candidates and parties take different stances in a zero-sum competition for voter support. Second, elite partisan polarization can stimulate polarization among ordinary voters. Taken together, these twin dynamics can undercut the processes of elite-led social learning and technocratic problem solving on which social progress to no small extent depends. The chapter shows how these distortions played out in 2009–10, when the Obama administration moved forward with its proposal for a major investment in research on the comparative effectiveness of medical treatments, despite the lack of public buy-in for this reform project.

This chapter examines how the politics surrounding efforts to address the medical evidence problem have been “unhealthy.” It shows that while the pragmatic case for bringing standardized evidence more systematically to bear on decisions in health care is compelling, federal politicians took only modest actions to support steps to identify and eliminate wasteful, unnecessary services between the 1970s and late 2000s. Moreover, politicians (responding to their electoral incentives) were quick to abandon even these incremental reforms when they sparked opposition from providers and the medical products industry. In sum, the government's performance as a problem-solving institution with respect to health care quality and efficiency was doubly disappointing. First, the medical guesswork problem was a low-priority concern, barely registering on the policy agenda; it was an “inside initiative” in which the conversation excluded both politicians and the general public. Later, when the medical evidence problem began to generate the broad attention it deserved, proposed solutions became the object of partisan manipulation and political distortion.

The Patient-Centered Outcomes Research Institute (PCORI) was established as part of the Affordable Care Act to promote research on the comparative effectiveness of treatment options. Advocates hoped this information would help reduce wasteful spending by identifying low-value treatments, but many conservatives and industry groups feared PCORI would ration care and threaten physicians' autonomy. PCORI faced three challenges during its first decade of operation: overcoming the controversy of its birth and escaping early termination, shaping medical practice, and building a public reputation for relevance. While PCORI has won reauthorization, it has not yet had a major impact on the decisions of clinicians or payers. PCORI's modest footprint reflects not only the challenges of getting a new organization off the ground but also the larger political, financial, and cultural barriers to the uptake of medical evidence in the US health care system. The growing attention among policymakers and researchers to provider prices (rather than utilization) as the driver of health care spending could be helpful to the political prospects of the evidence-based medicine project by making it appear to be less as rationing driven by costs and more as an effort to improve quality and uphold medical professionalism.

Since the enactment of the Affordable Care Act (ACA) in 2010, conservatives have sought to undermine the law's entrenchment. While they have failed in their ambitious quest to repeal the ACA, opponents have succeeded in overturning one major provision (the individual mandate penalty), narrowing the law's reach, complicating its implementation, and fomenting doubts about its political sustainability. This essay places the postenactment battle over the ACA in historical-institutional perspective by juxtaposing the strategic choices that conservatives have made to limit the role of the federal government in the core social welfare areas of pensions and health since the New Deal. Our central argument is that conservatives' varying strategies of postenactment opposition, resistance, and accommodation for Social Security, Medicare, Medicaid, and the ACA have been shaped by shifts in conservative ideology, changes in control of institutional resources, and the nature of policy feedback. Attention to these contextual factors helps explain why ACA opponents viewed the law as a threat despite its moderate policy design, why opposition did not subside after the law's enactment, and how conservatives managed to keep the conflict going across multiple election cycles.

In a number of important articles and books—most notably Agendas and Instability in American Politics (1993), The Politics of Attention: How Government Prioritizes Problems (2005)—Frank R. Baumgartner and Bryan D. Jones have pioneered a distinctive approach to the study of agenda setting that has shaped research in both the U.S. politics and comparative politics subfields. The Politics of Information: Problem Definition and the Course of Public Policy in America further expands on the theme of the political determinants, and implications, of “the organization and prioritization of information.” And so we have invited a number of political scientists from a range of subfields to comment on the book and on the research agenda more generally.

The U.S. medical system is touted as the most advanced in the world, yet many common treatments are not based on sound science. This book sheds new light on why the government's response to this troubling situation has been so inadequate, and why efforts to improve the evidence base of U.S. medicine continue to cause so much political controversy. The book paints a portrait of a medical industry with vast influence over which procedures and treatments get adopted, and a public burdened by the rising costs of health care yet fearful of going against “doctor's orders.” It offers vital insights into the limits of science, expertise, and professionalism in American politics. The book explains why evidence-based medicine is important. First, the delivery of unproven care can expose patients to serious risks. Second, the slow integration of evidence can lead to suboptimal outcomes for patients who receive treatments that work less well for their conditions than alternatives. Third, the failure to implement evidence-based practices encourages wasteful spending, causing the health care system to underperform relative to its level of investment. This book assesses whether the delivery of medical care in the United States is evidence based. It argues that by systematically ignoring scientific evidence (or the lack thereof), the United States is substantially out of balance.

President Barack Obama's two signature first-term legislative victories—the Affordable Care Act and the Dodd-Frank Act—are the law of the land, but the political battle over their entrenchment continues. The question now is whether these landmark reforms will be consolidated and create a new politics going forward. We develop an argument about the limits of policy feedback to illuminate the obstacles to durable liberal reform in the contemporary American state. We argue that political scientists have paid insufficient attention to the fragility of inherited policy commitments, and that the capacity of reforms to remake politics is contingent, conditional, and contested. Feedbacks are shaped not only by the internal attributes of policies, but also by the interaction between policy-specific characteristics, the strategic goals of officeholders and clientele groups, and the political forces arising from a contentious and uncertain political environment.

This chapter addresses the issues of using nonpartisan policy analysis within the current US legislative setting. It criticizes some of the earlier studies that assess congressional use of policy analysis for applying too narrow a conception of how analysis can affect decision making. The chapter conducts an original survey of over 150 policy professionals working in the Washington, DC, area and uses it to assess how well Congress carries out the different tasks or steps of policy analysis. It asks how well a certain institution carries out the policy-analytic mission rather than viewing policy analysis as the task of an individual or a small team focused on one particular issue.