I am a co-first author, in conjunction with Dr. Rebecca Meyerson of the University of Wisconsin, on a new study published in JAMA Network Open. We wanted to find out if ACA insurers responded to cuts in federal navigator funding on Healthcare.gov by increasing private television advertising. We found no detectable response.
We thought that we might have found something because advertising is information provision while navigators are both information providers and administrative burden reducers. There may be an imperfect substitution effect occuring:
In a precaution adoption process model for insurance enrollment, individuals proceed from being unaware, to aware but unengaged, to deciding to enroll or not enroll in coverage, to acting on their decision about enrollment.33 Navigators and advertising both plausibly increase the awareness and potential engagement of individuals, while navigators can also aid in navigating the process of choice and enrollment. Thus, for insurers seeking to raise profits by enrolling more people in marketplace coverage, advertising may be a substitute for public funding of the navigator program, albeit an imperfect one.
We think this is important to figure out because the state of Georgia has a 1332 waiver that is under current legal dispute. If Georgia can implement its waiver, Healthcare.gov is shut down in the state it is not replaced by a state based marketplace like the ones in Pennsylvania, California and Idaho. Instead, almost all functionality would be outsourced to private sector actors who have a profit maximization motive. We would like to see how private actors responded to a significant reduction in publicly funded outreach in the past.
We leveraged Dr. Meyerson’s previous work on the role of navigators. She and her co-author took advantage of the fact that there are two flavors of navigator programs. The first is a state wide program. Every county in a state is exposed to this program. The second type of program is a “local” or substate program. Some counties in some states received extra funding for more navigator outreach. This program design allows us to split counties into two groups — those with more navigator funding cuts and those with less. We then added in the Kantar/Campaign Media Analysis Group & Wesleyan Media Project television advertising data for a difference in difference analysis of ACA television advertising as our primary specification.
We found nothing:
We performed a whole lot of robustness and sensitivity checks as well as event studies to see if our results were a function of the model or a reflection of reality as best we determine. Our results in all of the sensitivity checks also returned neither pragmatic nor statistically significant results.
Insurers did not change their advertising offerings in response to a cut back in publicly sponsored outreach.
Insurer advertising has been shown to be pretty decent at claiming marketshare but not at increasing market size. We think that insurers are motivated to enroll people who are likely to be profitable which is a very different motivation than enrollment programs funded by the public and government.
We think that our evidence, or more importantly, lack of evidence, suggests that the Georgia waiver model that heavily relies on profit motives to provide enrollment outreach and navigation assistance is based on faulty assumptions as insurers did not respond to a large cut in navigator funding in the past during a time that insurers were, as a class, profitable as hell.
JustRuss
Color me shocked.
David Anderson
@JustRuss: There may even be gambling going on in this establishment….
PaulB
I know I shouldn’t be surprised, but this honestly just boggles my mind, that someone, anyone, would think this is a desirable scenario and a credible waiver request. It is so self-evidently and profoundly stupid that it is impossible for me to believe that this is being requested in good faith. It’s crap like this that makes me want to start screaming and throwing things.
The thing that really hurts is that these things have profound real-world consequences. Some people will die, other people’s lives will be permanently affected, because of this stupidity, should it be allowed to stand.
Ruckus
@PaulB:
The following is not aimed at you. I am ranting.
Money talks. And it talks louder than most anything else to a lot of people. And many people have been led to believe that government money is not a replacement for profits. And profit is the holly grail of everything. Therefore everything should make as much profit as possible. Healthcare has a large profit possible but only if left alone to itself. And as a “side” note a lot of people can not afford to pay for extremely profitable healthcare because they get paid crap because money is considered more important than their lives.
You very likely know all of the above, but it is not unreasonable to note that some people like money far more than humanity. Or anything else. And will screw their neighbors and fellow citizens to their death beds for an extra dime of profit. It is worth noticing that it is possible that 32 of the 33 most advanced nations have good, reasonable healthcare, controlled and paid for in good part by their governments. That one exception is surprise, surprise the United States of profit. And less you misunderstand, I’ve owned 2 businesses and actually do understand profit and loss. The difference is that health care is not a business that can afford to make a profit from the loss of it’s customers, it needs to not have a loss but not have a high profit at the expense of it’s customers because it’s an absolute need, not just a desirable one
And your rant is absolutely correct. There is a reason that so many nations interfere in their healthcare business and we don’t. PROFIT is that motive. In many cases it is actually racism that causes that interference.
jonas
It’s just icing on the cake that a lot of these states trying to minimize the number of people accessing ACA insurance or Medicaid are also the ones about to force a lot of women to carry high-risk pregnancies to term, which are phenomenally expensive to deal with. So we can’t treat your ectopic pregnancy until you’re literally about to bleed out on the ER floor, and on top of that you don’t have insurance! Super.
patrick II
@PaulB:
Heretic. You need to renew your faith in the free market.
oatler
The wheel turns, does it not?
trollhattan
Seldom (never) have useful input to the excellent healthcare series, but goddamn if I did not learn yesterday that my premium will go up 14.48% next year. 😲
delphinium
@trollhattan: Learned mine will be going up 22%, but am on the state insurance exchange so at least have the option of choosing a different (and hopefully cheaper) plan.
MazeDancer
Excellent work!
Victor Matheson
Nice landing for that piece. I thought it was interesting when you presented it at Holy Cross. Congrats!