UCL Institute of the Americas


Yifei Li

A Carefully Constructed Unintended Consequence: Development of Medicare as a Patchwork System, 1965-1997


Professor Jonathan Bell and Dr Nadia Hilliard

Expected completion date:

September 2023

My research explores the process of policy feedback through a case study of Medicare, a major public health insurance program for the elderly in the United States. When it comes to institutional change, proponents of the punctuated equilibrium model that emphasize the significance of exogenous forces have sometimes presented their arguments as refutations of the claims that focus on the incremental change promoted by political entrepreneurs as endogenous forces. However, these two strands of views are more compatible than they may appear to be. The core argument of this research is that some seemingly “unintended consequences” of Medicare are in fact carefully constructed by a long-term process. While a series of exogenous shocks, including the 1994 elections, fiscal deficit, and the retirement of the baby boomers collectively provided a critical juncture that brought extraordinary opportunities to reshape the program, it is this process of construction that made Medicare ripe for change.

This research explores to what extent was Medicare constructed by political tactics, such as symbolic reassurance, social construction of target groups, and political rhetoric. Employing historical institutionalism as major methodology, this research aims to illustrate the development of Medicare from 1965 to 1997 as a program jointly shaped by incremental change and radical reform. Furthermore, my research explores other possibilities of understanding policy feedback. In comparison with arguments that policies can be self-reinforcing or self-undermining, this research is open to the interpretation that only through a process of construction can policy effects become policy feedback.

Conference papers and presentations

A carefully constructed unintended consequence: Development of Medicare as a patchwork system, 1965-1997 | American Politics Group 47th Annual Conference, Political Studies Association (PSA), January 2021

Research experience

Research assistantship at Shanghai Academy of Global Governance & Area Studies, Sep. 2017 - Jan. 2019

Prizes and commendations

[since 2019]

1. International Relations Dissertation Prize for the best dissertation in IR for 2019-20.

2. Included on the Dean’s List as one of the students with most outstanding academic performance in the Faculty of Social and Historical Sciences.