Association for Public Policy Analysis & Management

The contrast in scale between the impact of the Affordable Care Act – which extended health insurance coverage to something on the order of six percent of the American population – and the role played by the ACA as a fulcrum of ferocious political opposition to the Obama presidency, presents a profound and intriguing puzzle. One way of unraveling this puzzle is to explore the power of narrative in public policy, and in particular its implications for the linkage of elite, expert and public opinion.

This paper proceeds in four sections. First, it presents a framework for investigating the power of narrative in the policy process. It distinguishes between expert discourses, based on analytic frames, and broad policy narratives invoking cultural and experiential understandings. Second, it argues that the role of each type of communication is different in different phases of policy development (such as welfare-state establishment, retrenchment and redesign), as mediated by the distinctive interest-based politics of each phase. Drawing on comparisons between the US and other nations, the paper argues that expert discourses and policy narratives can evolve asynchronously from each other, with the result that on critical occasions they can be sharply “out of phase” and disconnected. Third, it shows how the Obamacare conflict can be seen as just such a case. In most other advanced nations, frameworks of universal coverage were adopted in founding moments of welfare-state establishment, in which expert discourses and broader policy narratives were relatively synchronized in a contest between collective and individual responsibility. The US, in contrast, had the misfortune to pursue its final sprint toward universal coverage in a later phase of welfare-state redesign, when expert discourses had evolved to focus on specialized issues of system design. Grand narratives of solidarity were alien to that discourse, which yielded instead a highly complex technical compendium that was highly vulnerable to the simpler opposition narrative of an overweening state. Fourth, the paper concludes with some normative speculations about how policy-makers and their advisers can constructively use narrative methods, both strategically and heuristically.