Empirical Analyses of Associations between State Political Attitudes and Gains in Health Insurance Coverage after the Affordable Care Act (ACA)

Abstract

AbstractObjectivesTo explore whether state-level political-sentiment is associated with gains in insurance post Affordable Care Act (ACA). This is especially relevant given the lawsuit brought by several Republican-leaning states against the ACA, and the ruling of one Texas federal judge that the ACA is unconstitutional, which potentially jeopardizes ACA’s future.MethodsMultivariate linear-probability models are estimated using data from the Behavioral Risk Factor Surveillance Systems for 2011-2017. The outcome is self-reported insurance status. States are placed in quartiles based on votes for President Obama in 2008 and 2012 elections. Starting 2014, ACA health exchanges became active and several states expanded Medicaid, so 2014 onwards is considered as the ‘post-ACA’ period. Models are estimated for all adults under 65-years and for young adults under 35-years. All models control extensively for respondent socio-economic-demographic characteristics and state characteristics.ResultsIn the pre-ACA baseline period, respondents in states with higher Anti-Obama-voting (AOV) were less likely to have insurance. For example, residents in highest AOV-quartile states were 8.0-percentage-points less likely (p<0.001) to have insurance than those in the lowest AOV-quartile states. Post-ACA, fewer high AOV-quartile states expanded Medicaid, and overall insurance gains inclusive of Medicaid-expansion are similar across states. However, net of Medicaid-expansion, residents in higher AOV states saw higher insurance gains. For example, all adults had 2.8-percentage points higher likelihood (p<0.01) and young adults had 4.9-percentage point higher likelihood (p<0.01) of getting insurance in the highest AOV-quartile states compared to the lowest AOV quartile states. Minorities and those with chronic-conditions had larger insurance gains across the country post-ACA, but the extent of these gains did not differ by state AOV levels.ConclusionsState AOV and insurance gains from ACA appear to be incongruent. Policymakers and stakeholders should be aware that non-Medicaid residents of higher-AOV states might potentially lose the most if ACA is revoked.