Framing, engagement, and policy change: Lessons for the ACA

Andrew J Karch, Aaron Rosenthal

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Supporters of the Patient Protection and Affordable Care Act (ACA) sometimes speculate that public attitudes toward the law will shift if proponents succeed in focusing attention on its more popular components, but the scholarly literature on framing effects provides ample reason to question their assertion. This article contends that engagement, an alternative rhetorical strategy where advocates address the same policy dimensions as their opponents, is a more promising approach. Extending the engagement literature to the elite context in which most ACA-related decisions are made, it argues that elite-level engagement necessitates the additional task of linking policy change to opponents' broader philosophical and policy goals. Current debates surrounding the application of sales taxes to electronic commerce-a policy arena that seems far removed from health care policy but overlaps with the ACA in ways that make it an appropriate source of lesson drawing-illustrate the potential of an engagement strategy. Recently, many conservative lawmakers who previously opposed policy change have instead embraced online sales taxes as a mechanism for additional tax cuts. Analogous connections may facilitate the diffusion of ACA provisions that presently receive hostile receptions in Republican-leaning states.

Original languageEnglish (US)
Pages (from-to)341-362
Number of pages22
JournalJournal of health politics, policy and law
Issue number2
StatePublished - Apr 1 2017


  • Health care reform
  • Policy diffusion
  • Rhetorical strategies


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