Last December, the Journal of Health Politics, Policy and Law published a fascinating article by Sam Trachtman.** He looked at a relevant policy-politics feedback loop. What did ACA premiums look like for non-subsidized individuals in Republican and Democratic leaning counties?
Insurers have increased marketplace premiums at higher rates in areas with more Republican voters. In the preferred model specification, a 10-percentage-point difference in Republican vote share is associated with a 3.2-percentage-point increase in average premium growth for a standard plan….
One way to investigate this dynamic is to look at geographic variation in premiums. In particular, premiums would be expected to be higher in areas with more Republican partisans. Figure 1 demonstrates that in 2017, there was a strong positive relationship between county-level Republican voting and individual marketplace premiums, while this relationship was slightly negative in 2014. This suggests that insurers systematically underestimated health spending in Republican-leaning areas relative to Democratic-leaning areas, a pattern that could be attributable to the interaction between partisanship-motivated enrollment and adverse selection….
Recent scholarship indicates that the uptake decisions that individuals make with respect to the ACA are driven in part by their political partisanship. Using individual-level survey data from Kaiser Health Tracking polls, Lerman, Sadin, and Trachtman (2017) estimate that, ceteris paribus, Republicans are 6 percentage points more likely to forgo coverage than Democrats, 12 percentage points less likely to use the ACA marketplaces, and 7 percentage points more likely than Democrats to purchase plans off-marketplace. Analysis of Cooperative Congressional Election Study (CCES) data yields similar conclusions (Tesler 2015).
People process information through subjective lenses. Partisanship is a major lens through which health and health insurance information has been processed over the past decade.
** Samuel Trachtman; Polarization, Participation, and Premiums: How Political Behavior Helps Explain Where the ACA Works, and Where It Doesn’t. J Health Polit Policy Law 1 December 2019; 44 (6): 855–884. doi: https://doi.org/10.1215/03616878-7785787
Ohio Mom
That is very interesting. Are we surprised Republicans tend to make dumb decisions, No.
But so fun to see our perceptions validated by data.
Now how to use this information to make an end run around them and get them proper coverage despite their self-defeating behaviors?
JPL
Leadership starts at the top and elections matter.
Big R
Haven’t read the article, so this may be a dumb question, but does he control for partisanship of state insurance commissioners? Seems like more Republican states will be more likely to have Republican regulators, who might be more hands off and approve higher rate increases.
Wag
So partisan fears about the ACA and insurance costs become self fulfilling prophecies for the GOP. Interesting
David Anderson
He looks at implementation decisions in another paper ( doi.org/10.1215/03616878-7893591 )
For this paper, he is using state fixed effects for most of the political controls past the variable of interest; 2012 GOP vote share. I don’t think this is ideal, but it is probably good enough for the time period he is examining.
Amir Khalid
True. But uniquely in America, health care and its provision are fought over between the main political parties, for which one could thank* Cleek’s Law Republicanism. I certainly can’t think of another country where healthcare is a political football.
*If thank is the word to use
Jerry
I think “blame” works fine there, Amir
Mike J
I’ll add a dumb question: Older people cost more to cover. Older people are more likely to vote Republican. Are these related?
JaneE
I suspect the not-rich Republicans have a lot of untreated issues that catch up with them when they do get insurance, raising the cost of their treatment. Before ACA a lot of people avoided and put off things they knew they needed because of cost. I know a couple of them. One was before the ACA and they deliberately did not see a doctor for years because they didn’t want a diagnosis on their record when they could finally afford insurance. By the time they broke down and bought a policy, the damage required two surgeries and they are still left with permanent impairment. The other thought they had lung cancer, but couldn’t afford to see a doctor, plus the fear of finding out. Bought an ACA policy as soon as the exchange went live, saw a doctor, and found out it was a treatable form of bronchitis – one month later was practically dancing around. They did take some snide comments from dedicated GOPers for buying socialized medicine. Apparently around here being Republican means that you really care about your friends, unless they use Obamacare and then you wish they had died instead.