Enroll America

Do political attitudes affect who has health insurance coverage?

The decision to enroll in a public program, frequently referred to as “policy uptake,” depends on a variety of factors: perceptions of stigma; the availability and accuracy of information; and the structure of incentives and penalties. In partnership with Enroll America, we tested the idea that uptake is not just about information and incentives; it is also about attitudes towards government.

According to 2016 estimates, about 20 million Americans gained health insurance coverage after the ACA became law. However, millions of Americans remained uninsured despite the threat of financial penalties for failing to enroll. In the second quarter of 2016, after the end of the third enrollment period and roughly six years after the ACA was passed, more than one in ten adults still reported being without insurance coverage.

To test the attitudes towards government affecting policy uptake, Possibility Lab partnered with the Kaiser Family Foundation and Enroll America to examine participation in the state and federal health insurance exchanges, which were set up as part of the Affordable Care Act (ACA), also called “Obamacare.” We find that Republicans were systematically less likely than Democrats to enroll in an insurance plan through a state or federal exchange in the years after the ACA was passed. However, using a large-scale field experiment, we also find that framing enrollment in a way that emphasizes the “private” nature of the ACA and de-emphasizes the government’s role substantially increased insurance uptake among Republicans.

Our results make clear that partisan politics do not end when policies are passed. Rather, partisanship interacts with policy framing to influence enrollment behavior. This suggests that, despite potentially large returns for many government programs, benefits to individuals and society are not a foregone conclusion once a policy is implemented. Rather, the extent to which individuals take advantage of public services is determined by both supply-side (policy framing) and demand-side factors (individual partisanship). The extent to which these factors influence uptake will vary depending on the policy and context. However, given the fairly low levels of uptake that have been documented across a wide array of programs, our findings have important consequences for the success or failure of government efforts to improve individual health and well-being.

This project was made possible with funding from the Russell Sage Foundation.