Date of Award




Document Type


Degree Name

Doctor of Philosophy (PhD)


Department of Political Science

Content Description

1 online resource (iii, 195 pages) : color illustrations.

Dissertation/Thesis Chair

Patricia Strach

Committee Members

Julie Novkov, Zsofia Barta


democratic decision making, health, healthcare, private policy, public policy, Medical policy, Health services administration, Policy sciences

Subject Categories

Public Policy


On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law, thereby ushering in the most sweeping, expansive changes to the American healthcare system since the creation of Medicare and Medicaid in 1965. Supporters, including healthcare advocates, celebrated the passage of the ACA as a defining moment in healthcare history. As broad policy reform influenced practice on the ground in the months and years after passage, physicians working in private practices and hospitals changed some things about the way that they treat patients. Yet, following interviews with doctors and medical office practice managers to talk about these experiences, directives linking the changes on the ground to specific policy guidance in the ACA legislation itself, are absent. If policies passed by Congress were not responsible for the changes physicians experienced in their practices following passage of the ACA, what was? By examining a lesser-known provision in the ACA — bundled payments for healthcare services under the Medicare program — significant changes to health practices originating through the private sector, instead of arising through bills passed by Congress, or from express regulatory authority derivative of the reform statute itself, arose. Findings suggest that when scholars study the public policymaking process by focusing on elected officials and public debates, they privilege the dominant narrative for policy creation and exclude considerations of other, equally powerful policymaking processes. The private-actor policymaking framework shows how a program that incentivizes private actors to take action, and then makes those actions the standard for public programs, changes the calculus of policy winners and losers in the healthcare realm, and operates as a powerful determinant of policy direction and control.

Included in

Public Policy Commons