Welfare State Eras, Policy Narratives, and the Role of Expertise: The Case of the Affordable Care Act in Historical and Comparative Perspective

This article presents a way of understanding the linkage of expert and public opinion through a focus on policy narratives, which serve as deliberately crafted rhetorical bridges between expert discourses and broader cultural experiences. Across advanced nations, the dynamics of this bridging function has differed in different phases of policy development (such as welfare-state establishment, retrenchment, and redesign), depending on the state of discourse in each realm. In the establishment phase in which most programs of universal health care coverage were adopted, expert discourses were relatively synchronized with but subservient to broader policy narratives about collective and individual rights and responsibilities. The United States, in contrast, pursued its final sprint toward universal coverage in a later phase, in which the policy analysis community had greatly expanded and expert discourses had evolved to focus on specialized issues of system redesign. The resulting highly complex technical design did not readily align with an epic narrative of public purpose. Advocates instead relied principally on two narrative lines: an aggregation of anecdotes that was vulnerable to the simpler opposition narrative of an overweening state, and a crusade narrative that met the opposing narrative of patriotic resistance on its own terms but could not allay partisan polarization.