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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.

In contrast to “targeting within universalism,” in which extra benefits are directed to low‐income groups within the context of a universal policy design, the reliance of mainstream elderly on means‐tested Medicaid benefits represents the inverse pattern of “universalism within targeting.” During moments of intense debate, policy elites have strategically reframed Medicaid as a broad‐based social entitlement, yet many politicians remain ambivalent about using a program originally intended for the poor to protect the middle class. The analysis suggests that universalism and targeting are best seen not as fixed, technical features of program structures but rather, as the political raw materials with which politicians contest the multiple and conflicting purposes of the American welfare state.

Medicare features an unusually complex financing design. The Hospital Insurance Trust Fund pays for Part A of Medicare (hospital stays), while the Supplementary Medical Insurance Trust Fund finances Part B (doctor visits,outpatient care, and certain home health services). At a time when Medicare policy is generating debate, this article takes a new analytical look at the origins and consequences of the program's peculiar bifurcated structure. Addressing historians of the U.S. welfare state as well as contemporary health policy reformers, the article focuses on the crucial role of legendary Ways and Means Committee chair Wilbur Mills in Medicare's enactment in 1965. The central theme of the article is that fiscal conservatism and a commitment to budgetary restraint constitute important elements of Medicare's original political understanding. Contrary to analysts who argue that Medicare's financing design has produced “perverse” effects, we argue that it has served a valuable social function by encouraging policy makers to confront periodically the costs of one of the largest and fastest-growing federal programs. An argument can be made that Medicare's original division requires modification in order to integrate health care delivery changes of the past few decades. It is crucial, however, for reformers not to lose sight of the policy goals, including fiscal rectitude, that motivated the adoption of Medicare's bifurcated structure in the first place.

Long the lifeblood of public administration, budgeting in the United States acquired a new importance during the 1980s and 1990s because of the fiscalization of the policy debate. But how much has American national budgeting really changed? This article examines the evolution of federal budgeting over the past half-century, exploring such developments as the massive growth of entitlements, congressional budget reform, and the protracted battle over the budget deficit. It finds that year-to-year changes in budget results have been relatively small even while budgetary rules and procedures have experienced sweeping change. At the same time, the composition of federal spending has undergone a quiet revolution. The traditional concept of budgetary incrementalism offers an incomplete explanation for these dynamics. To make sense of them, the article focuses on two key factors: the impact of policy inheritances, and the role of actors' causal and normative beliefs. These factors shape the ideational and material context within which boundedly rational actors negotiate decisions. The tension between changes in ideas and entrenched budgetary commitments has often served to stimulate institutional reform.

Long-term policy commitments pose a fundamental dilemma for democratic polities. Unless officeholders can devise ways of credibly committing themselves and their successors to a particular policy path, many desirable social outcomes will be unattainable. Yet if prior policy commitments are irrevocable, governments will lose the flexibility they need to respond appropriately when conditions change. This tension between credibility and flexibility, in which the present struggles with the future and with the past plays out in countless policy domains.1 Nowhere is this tension more evident, however, than in budgetary politics. As the end of the twentieth century approaches and aging populations become eligible for retirement and health programs, industrial democracies around the globe are finding that their fiscal policies are more and more being driven by what economist C. Eugene Steuerle aptly describes as the "yoke of prior commitments."2 Despite the relative stinginess of the American welfare state, the United States has not been immune from this trend. Prior commitments for Social Security, Medicare, and other programs, combined with the elimination of "bracket creep" by the indexing of income taxes, have all but eliminated fiscal slack in the federal budget. One need not be an enemy of public social provision to worry about the attendant loss of fiscal policy discretion.

As the new century begins, the Medicaid program is arguably at a political crossroads. Over the 1980s and 1990s, policy makers enacted major expansions in Medicaid coverage, offering significant new health benefits to poor women and children and other constituencies. In elite rhetoric and political framing, Medicaid was increasingly cast as a broad-based social welfare entitlement of value to all Americans, including middle-class citizens. Some health care advocates began viewing Medicaid expansions as a potential path to achieving universal coverage in the United States. Yet Medicaid remains a means-tested program that has been repeatedly threatened with policy retrenchment. In this essay, we scrutinize Medicaid's current status and future possibilities from a historical-institutional perspective by tracing its complex evolution since its enactment in the Social Security Amendments of 1965. Our core claim is that decisions made at the time of Medicaid's original adoption have fundamentally set the matrix for struggles over the program's unfolding development. We demonstrate that key ambiguities embedded in the 1965 act created largely unintended opportunities for policy entrepreneurs to broaden Medicaid's scale and scope as well as foreseeable vulnerabilities that must be overcome if Medicaid is to realize its full potential.