In the language of social science, health policy is both an independent variable and a dependent variable, both a cause and an outcome. The decisions of health policy makers are the product of political, economic, cultural, social, and historical forces. And once made, these decisions shape a range of outcomes, including the quantity and quality of care that patients receive, the level of public and private investment in hospitals, and the political participation and beliefs of citizens. The articles in this issue nicely capture the reciprocal relationship between health politics and policy. Taken together, they demonstrate that the substance of health policy cannot be understood without reference to the political context in which policies are crafted or to the ways that political institutions and ideas mediate program design, the organizational and financial incentives of stakeholders, and even how patients perceive their own self-interests.
In our first article, Ashley Tallevi examines how privatization—the delegation of administrative authority to nonstate actors—affects whether Americans recognize the health care benefits they receive. Research by political scientists such as Suzanne Mettler (2011) has shown that “submerged” policies that rely on private delivery mechanisms, such as tax expenditures, lead recipients to underestimate the extent to which they engage with and benefit from government actions. Key questions remain, however, about the specific influence of privatization on people's understanding of whether they are the recipient of a government program. Leveraging variation in the implementation of Medicaid managed care, Tallevi's analysis shows that privatization of a major social program can lead to decreased awareness of program use but that not all privatization initiatives have the same effect. The design of privatization schemes matters a great deal. In particular, the use of certain administrative elements that obscure the role of the state is correlated with a larger proportion of the Medicaid population failing to recognize and report their enrollment. In sum, certain forms of privatization make it demonstrably harder for program beneficiaries to engage in the civic sphere as informed advocates for their own interests.
Public opinion and civic participation are shaped not only by the administrative design of health care policies but also by the messages that people receive about the rationales for different government programs. Political science research has shown that the public's willingness to pay higher taxes to expand particular services is influenced by the way the policies are “framed,” but it is not always clear to policy advocates what narratives or arguments will be most persuasive. All too often, without the benefit of hard data, advocates have little choice but to fall back on their own intuition—which may or may not be accurate. In our second article, Emma E. McGinty, Howard H. Goldman, Bernice A. Pescosolido, and Colleen L. Barry demonstrate the knowledge gained through a careful empirical study of the persuasiveness of different communication strategies. Their substantive focus is the policy debate over how best to address serious mental illness (SMI). A major controversy among mental health advocates is whether it is necessary to draw attention to an apparent link between SMI and violence (shown to elevate stigma) in order to increase public support for investing in mental health services, or whether nonstigmatizing messages can be equally effective. To answer this important question, the authors conducted a survey experiment on a nationally representative online panel. Survey respondents were randomized to a control arm or to read one of three narratives about SMI emphasizing violence, systematic barriers to treatment, or successful treatment and recovery. The study found that narratives emphasizing violence and barriers to treatment were equally effective in increasing public willingness to pay additional taxes to improve the mental health system and that both were more persuasive than the control arm. The implication is that mental heath advocates who seek to build public support for improvements to the mental health system have a viable alternative to stigmatizing messages linking mental illness and violence.
The design and framing of health policies affect not only public attitudes and political participation but also the health care benefits actually delivered to people on the ground. In the third research article, Simone Singh, Gary Young, Lacey Loomer, and Kristin Madison examine the effectiveness of state-level regulations intended to enhance the accountability and oversight of nonprofit hospitals regarding their provision of community benefits. More than half the states require nonprofit hospitals to disclose their community benefit activities, and some states impose additional requirements that nonprofit hospitals must satisfy to maintain their tax-exempt status. But do these regulations actually have an impact? The authors investigate this question through a statistical analysis of community spending for more than eighteen hundred hospitals. Overall, they found that state-level benefit regulations are associated with greater community benefit spending but that some regulations (such as minimum income eligibility standard for charity care) have no apparent impact on nonprofit hospitals' provision of community benefits. The results of the study can help inform efforts to improve the design and enforcement of regulations to encourage hospitals to serve their communities in ways consistent with policy makers' goals.
In our fourth research article, Philip Rocco and Simon F. Haeder provide an empirical perspective on the multiyear effort of the GOP to “repeal and replace” the Affordable Care Act. Focusing on “intense policy demanders” within the Republican party, the authors develop an original database of bill introductions in the House of Representatives between 2011 and 2016. They show that more conservative House GOP members and those receiving a higher level of business-sector contributions were significantly more likely to introduce legislation aimed at repealing or significantly altering the ACA. While this finding is not unexpected, the study has broader implications for research on the role of business organizations and conservative activists in shaping the postenactment of health reform, as well as for scholarship on theories of policy entrenchment and durability. A key takeaway is that the fate of the ACA and perhaps other key welfare state programs will be determined by the clash between the positive policy feedback generated by the provision of social benefits to individuals and groups, on the one hand, and the pressures from the “asymmetric mobilization” of policy demanders within the Republican party, on the other.
Finally, in our “The Politics and Policy of Health Reform” special section, Dylan H. Roby and colleagues provide a timely report on the New York Delivery System Reform Incentive Payment waiver's design, early experience, and evolution.