Three Essays on Health Policy and Politics

Abstract

Health is both an output and an input of the policy-making process. Public policies shape people's access to health insurance, experiences in the health system, and the structural determinants of health. In turn, people's health and experiences with public institutions shape their political preferences and behaviors in a self-reinforcing cycle. To be sure, health is one of many considerations in policy making and politics, yet it is inextricably intertwined with these other domains; health and ability enable people to maintain gainful employment, socialize with loved ones, engage in civic life, and more. This dissertation explores this cycle using the theoretical and empirical tools of political science and economics. Chapters 1 and 2 consider health and experiences with public institutions as inputs into the political system, and Chapter 3 examines insurance markets as an output of public policy. Chapter 1 asks whether transformational public policies can shift one of the most fundamental political identities: partisan identification. Most political science theories on partisan identification agree that people's parties are typically stable throughout their lives and change only rarely on the margins. However, my coauthors, James R. Jolin and Andrea L. Campbell, and I argue that public policies might lead people to reconsider their party affinities under several strict criteria --- which the Affordable Care Act (ACA) of 2010 meets. Using nationally representative survey data over 17 years, we leverage the natural experiment of Medicaid expansion under the ACA and apply a difference-in-differences with event study framework to show that the law led millions of Americans to realign themselves with the Democratic Party. The effect has endured for nearly a decade. Then, using several additional data sources with both causal and descriptive approaches, we disentangle the mechanisms underlying this shift, finding important roles not only for the provision of health insurance but also for the messaging behaviors of political elites. The findings have important implications for our theoretical understanding of partisan identification and policy feedback, and they suggest that the public is willing to reward political actors for major policies. Chapter 2 asks how health and experiences with the health system relate to an even broader set of political attitudes: support for democratic systems. This question is timely as public institutions across the world struggle with a crisis of low public trust, and many formerly strong democracies are at risk of or actively sliding into authoritarianism. Few, if any, studies on these trends have examined the roles of health and the health system, despite their relevance to diverse aspects of people's lives. My coauthors, Christopher Ojeda, Kevin Croke, and Margaret E. Kruk, and I use a rich variety of descriptive tools to document the consistently strong associations between worse health or ability and greater discontent with an array of democratic institutions and values, ranging from faith in elections to confidence in the democratic system. In doing so, we use data from more than 1 million person-years, representing 88% of the world's population. We also find that negative ratings of the health system and other public institutions may be a key mediator of the relationship between poor health and democratic discontent. Although we lack clear causal evidence, the descriptive evidence makes clear to policy makers that people in poor health are grossly dissatisfied with their democratic institutions and may be ideal targets for efforts to rebuild trust. Lastly, Chapter 3 takes on a classic economic question: How does public regulation of insurance markets affect firm competition and consumer welfare? Specifically, my coauthors, Timothy Layton, Borin Vabson, Michael E. Chernew, and J. Michael McWilliams, and I examine the consequences of reducing inertia in Medicare Advantage markets. Although other work has documented the negative effects of inertia on consumer welfare, few, if any, studies have shown that policies to counteract it can induce competition among firms. We take advantage of a policy change in 2019 that pushed hundreds of thousands of Medicare beneficiaries in Minnesota --- most of whom would have remained in the same plan --- to reconsider their coverage options. Because the policy differentially affected counties, we can apply a difference-in-differences with event study framework. In doing so, we find that the push toward active choice induced greater competition among firms, with the entry of several new insurers into the Minnesota market, and the proliferation of higher-value plans among existing insurers. Consequently, beneficiaries had access to a richer set of plans with wider networks of hospitals and providers and more supplemental benefits for similar or lower costs. The findings suggest that efforts to reduce inertia in health insurance markets (and possibly other settings) could incentivize firms to field more competitive offerings. Taken together, these papers document the complex interplay between health, public policy, and politics. For academics, they provide new theoretical insights into the behaviors of firms and consumers in inertial health insurance markets, as well as how experiences with health and health-related institutions shape people's politics. For policy makers, they make clear not only that public policies can protect and promote the welfare of populations, but also that populations will, in turn, reward political actors and institutions for them.