Essays on Health Insurance: Public Opinion and Consumer Behavior

Abstract

In this dissertation, I consider health insurance coverage in the United States from two perspectives. I open with a high-level analysis of trends in public opinion that underpin current political debates around health reform. My second two papers use administrative data from the Massachusetts Health Connector to characterize enrollment behavior in the nongroup health insurance market. Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency—and the sitting president—have endorsed health reforms that would radically transition American health care away from the current system, upon which the ACA built. In Chapter 1, I use a 2019 nationally-representative telephone survey to evaluate how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor “Medicare for All” over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who favor would replace it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA but reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs. The nongroup market for health insurance, which serves individuals who don’t have access to coverage through an employer or public programs, is known to experience high levels of churn. However, the reasons for disenrollment from this market are poorly understood. In Chapter 2, I aim to clarify these dynamics using an administrative data set from the Massachusetts Health Connector. To obtain causal estimates, I leverage a natural experience for the 2017 plan year and use an event-study approach to study enrollment consequences of introducing a nominal ( $10) premium for plans that previously did not require a monthly contribution from enrollees. I show that nearly one in five enrollees who face a new, nominal premium are terminated for nonpayment by the end of the new plan year. As a first-order matter, enrollment inertia is an important determinant of these outcomes; all affected enrollees had the option to switch into a zero-premium plan offered by a different carrier at the start of the plan year. Comparing termination rates across plans that imposed different-sized premiums suggests that this disenrollment is predominantly driven by the administrative burden of initiating and sustaining premium payments, though there does appear to be a modest role for affordability. Chapter 3 uses the same administrative data set to evaluate how take-up of individual market insurance during the COVID-19 pandemic compared to enrollment during prior years. I show that new enrollees who entered the Massachusetts individual market during the COVID-19 special enrollment period were younger, on average, and more likely to enroll in unsubsidized coverage than mid-year enrollees in 2017-2019. I also offer suggestive evidence that the state's special enrollment period—which relaxed administrative burdens typically required to enroll mid-year—may have improved take-up of coverage.