Affordable Care Act: What We Don’t Talk About When We Talk About Politics

Authored By 
Bao Bao Zhang
Blog contributor 
Policy Fellow

Four years after the passage of the Affordable Care Act (ACA), access to affordable health care remains highly politicized in the U.S. Politicians fiercely debate the cost and legality of the ACA. While we know that partisan elites have rallied around or against Obamacare, we don’t know much about how the program has affected its nearly 8 million enrollees’ political attitudes and behavior. While research has primarily focus on the health impacts of the ACA, policymakers could also benefit from learning whether access to health care leads to greater civic engagement — a boon for democracy, as well as for the staying power of the ACA.

Many scholars have observed that policies that affect large numbers of Americans tend to change mass politics. So far, they’ve found that universal welfare programs tend to increase recipients’ political efficacy. The creation of Social Security increased senior citizens’ political participation and led to the creation of lobbies that advocate on retired voters’ behalf . The GI Bill, which helped 7.8 million WWII veterans attend college or vocational training, initially increased political participation and had the strongest lasting effects on those who attained the highest level of education.

On the other hand, means-tested poverty alleviation programs seem to have the opposite effect – they do not tend to change recipients’ political efficacy, and might even depress civic participation. There is a negative association between voting in elections and receiving benefits through Aid to Families with Dependent Children (AFDC). Likewise, there exists a negative correlation between receiving welfare and electoral participation among young adults. Scholars argue participants in these programs are already politically marginalized and signing up for stigmatized aid might even lower their likelihood to participate..

How will the ACA affect mass politics? Will it look more like Social Security or the AFDC?

While the ACA funds means-tested programs, applicants may feel less of a stigma signing up given the Obama administration’s attempts to put a positive spin on the health care exchanges. Furthermore, because Obamacare has been constantly under attack by Republicans, enrollees might feel more compelled to engage in politics to defend their benefits.

On the other hand, Republicans’ fear that recipients of Obamacare will turn into active Democrats is unfounded. The type of Americans who have signed up for health care on the exchanges are hardly party activists with money to spend on donations or time to volunteer — or even go to the polls.

In short, we know very little about how the ACA will affect mass politics. But the tools of modern social science can help us answer this question if we are willing to devote resources to researching it.

Health economists have already investigated how affordable health care impacts personal finance and education. Using a randomized field experiment in Oregon, economists find that Medicaid decreased the probability of having an unpaid medical bill sent to a collection agency by 25 percent and virtually eliminated out-of-pocket catastrophic medical expenditures. In another study, by comparing children who barely qualify for Medicaid with those who barely disqualify, researchers found that Medicaid reduces children’s probability of missing excessive days of school.

Political scientists can use similar methods to study how the ACA affects enrollees’ electoral participation and civic engagement. My current research focuses on the political impacts of the expansion of Medicaid, a key component of the ACA. By analyzing the downstream political behavior of subjects in the Oregon health insurance field experiment, I hope to learn whether receiving Medicaid changes enrollees’ propensity to register to vote and to participate in local, state, and national elections. Expanding beyond Oregon, I hope to use existing data and new surveys to compare political attitudes of low-income Americans in states that have expanded Medicaid under the ACA and in neighboring states that have not.

When policymakers and the news media chatter about the ACA and politics, they rarely talk about how the expansion of affordable health care will impact the political attitudes and behaviors of those benefiting from the problem. The answer to this question may play a large role in shaping Obamacare in the future. The low-income Americans ACA seeks to help already lack influence in shaping government policy compared with the wealthy who are subsidizing the program. Therefore, if the new recipients of Medicaid and those who champion their cause fail to mobilize politically to defend the ACA, the most significant health care regulatory legislation in decades might see a gradual death over the next few years.

Baobao Zhang is a second-year PhD student in political science and a master’s student in statistics. She is also currently a Graduate Policy Fellow at ISPS.

Area of study 
Political Behavior