In this month’s American Journal of Health Economics, Hopkins et al estimate the percentage of people who take-up ACA health insurance for the eligible pool for the 2015-2017 plan years. They use a combination of de-identified micro-data from Healthcare.gov and the American Community Survey to generate these estimates. They find a few expected things including that when people have the ability to make a good faith estimate that either qualifies them or disqualifies them from benefits, those estimates will be optimistic. Take-up was fairly low but it increased by age. One of the things that really leapt out at me was the gender splits:
They offer a few of the standard explanations. Women are socialized to engage in more health seeking behavior is a common explanation. One of the ones that was not mentioned in the text but I think needs to be explored some more is partisan take-up. We know from Lerman et al (2017) that political identity meant a lot in early ACA take-up:
First, we find that partisanship has a strong and statistically significant relationship to whether individuals have health insurance. The evidence indicates that, all else equal, Republicans are 6 percentage points more likely than Democrats to be uninsured. Second, we find that partisanship is strongly associated with opting to purchase marketplace plans. With the full set of controls, we find that Republicans are fully 12 percentage points less likely to purchase marketplace plans than Democrats.
Gender is not a bad first pass predictor for partisan affiliation and identity. Opposition to the ACA was a highly visible and salient component of Republican identity in 2015-2017 when this study was conducted. I am curious if some of the take-up effects that are being captured in the Hopkins et al article is really a political effect rather than a health economics health seeking behavior effect?
Anonymous At Work
Why can’t the take-up effects be both political and health-seeking behaviors as a result of women’s health issues driving the gender-based partisan gap? The underlying assumption for men is that health care for them is standard, ‘women’s issues’ is extra/superfluous.
narya
Women want that yearly gynecological exam. Many women who didn’t have access to the HPV vaccine probably had an abnormal Pap smear at some point and want to make sure it doesn’t recur/get worse. Good luck taking care of that w/o insurance. Also: access to some forms of contraception requires (used to require? don’t know what the current situation is) that visit as well: oral contraceptives, LARCs, etc. That is, I don’t think the “socialization” argument is complete–managing fertility requires that visit, and it will be prohibitively expensive w/o insurance.
NutmegAgain
Super interesting. Curious what happens if you add parental status to your model? When I saw the gender difference, I immediately thought that mothers are far more commonly the ones who engage the health care system on behalf of their kids. (See for example the current Help! Advice! column in WaPo, which is yet another plea for help in getting husband to take on more of this behavior. But seriously.) I have no data to point to, so this is very much a seat of the pants, anecdotal type of query. But I’d be interested. The intersections of gender, family roles, and caretaking behavior of all sorts is certainly documented.
H.E.Wolf
Indeed. Gendered socialization re: health care would be a “necessary but not sufficient” reason.
In addition to the important issues mentioned by narya, there are many other fertility-connected matters relevant to women and girls, which might be an incentive to seek health care and health insurance (bearing in mind that health insurance and health care are two separate things):
dysmenorrhea; uterine fibroids; ovarian cysts; menstruation-related anemia; infertility; pregnancy; abortion.
H.E.Wolf
Another excellent point, and another good example of gendered socialization [I’m making this phrase do a lot of work].
Anonymous At Work
@H.E.Wolf: It’s a great point but likely to be victim to limitations on de-identified/anonymous data sets (helloooooo, day job!).
I’d want to see marital status and employment information (type, wage/salary estimates, etc.) since this is ACA enrollment, separate from employer-provided.
Professor Bigfoot
@Anonymous At Work: I’d also like to see the data broken out by demographic… THAT is a better indicator of partisan identity, IMO.
Another Scott
Interesting, and seems to fit with other datasets. E.g. KFF.org (from December 12):
Much more at the link.
Thanks and HNY to you and yours.
Best wishes,
Scott.
sab
@narya: I agree. My family is remarkably healthy. None of us needed any kind of medical attention except for prescribed birth control.
And I am old enough to remember when a single woman could not get health insurance period. It was only available through her husband’s policy.
NutmegAgain
@H.E.Wolf: Once upon a time I was a (genuine, certified) social scientist who studied stuff like gender & medicine. Evidently I can still rub a few of those brain cells together!
justsomeguy05
I enjoy how the “male” color is the one closest to pink, and the “female” color is the one closest to blue. I know they are not ACTUALLY pink & blue, but at first glance some might assume the genders in that chart are the opposite of what is depicted.
EmbraceYourInnerCrone
@Anonymous At Work: Its also fun when one has to repeatedly seek treatment for a health issue and have it be put down to anxiety and oh have you tried losing weight…umm I had a form of severe endometriosis but thanks for ignoring my pain for years docs…same with migraines. I suppose I could have ignored the tachycardia too oh yeah I did until the bradycardia landed me in the ER..”why didn’t you say something sooner” well cuz I m pretty sure I would have been ignored again or told I was having a panic attack. Narrator: she was not in fact having a panic attack…did get a shiny new pace maker tho…