The Affordable Care Act was a huge change in public policy. The two bills within it were a priority for President Obama, who wanted to focus on health care as one of his core issues. One of the course concepts we mentioned in discussion of the Presidency was limits on their legislative power—due to national crises, available time, and the willingness of Congress, executives often must carefully pick their issues. Oftentimes, their biggest power in this process is their personal popularity and their ability to negotiate. According to an interview with Congressional staffer Liz Fowler, who worked on the bill, “presidential leadership is absolutely critical.” Obama’s commitment to the issue of health care, as well as Democratic control of Congress, were major factors in passing the ACA. Fowler mentions Obama’s well-educated approach on the issue, as well as his ability to leave himself out of Congressional work and allow them to write the bill.

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One strategy for the presidential agenda is the bully pulpit, or the use of public statements. Fowler acknowledges this method, saying “I think part of what he did was through public statements, his joint address of Congress, emphasizing how important this issue was.” She also says Obama held and important behind-the-scenes role, speaking with members of Congress frequently and maintaining focus. The description of the president’s role in the landmark legislation reflects what we learned in class on the personality tools available to the executive.

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The actual execution of the Affordable Care Act and United States healthcare as a whole falls largely on another body discussed in the course—the bureaucracy. Health care is a perfect example of an issue network, as it involves Congress, various bureaucratic departments, almost the entire public, pharmaceutical and medical technology companies, private and public hospitals, private insurers, employers, and providers. The complexity of the issue is echoed in the complexity of the administration, with most services being administered through the Department of Health and Human Services, with some exceptions. For example, the requirement that non-profit hospitals assess and address community needs is overseen by the Internal Revenue Service. Like other bureaucratic practices, these reports on non-profit hospital action are open to the public.

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One common feature of the bureaucracy is contracting work to other organizations. In the field of healthcare, this is represented by the role of private insurance. Public programs, such as Medicare, often utilize private insurers. Additionally, one of the main criticisms of health care is the administrative cost. This is due, in part, to the scope of the bureaucracy. Because the system incorporates so many public and private entities, it requires extensive regulation and red tape. This is a large reason why people argue in favor of a single-payer system—having one, government-funded health care option could reduce the responsibilities of the bureaucracy.

The full extent of bureaucracy in health care is best summarized by this chart, from the Commonwealth Fund: