Every public policy produces consequences for beneficiaries and other members of society. For example, Social Security reduces the poverty rate among senior citizens, which in turn relieves the financial pressure on adult children to provide financial support to their aging parents. In this case, a public policy (Social Security) produces effects in line with the aspirations of its designers. Intended impacts, however, are not the sole (or even necessarily the most important) ways that public policies affect people. The most important effects—whether positive or negative—of a given policy may have been unanticipated when it was enacted. Investigating these surprising consequences and exploring their causal mechanisms are important tasks for researchers.
In our first article, Leonard M. Lopoo, Emily B. Cardon, and Kerri M. Raissian show that the impact of the dependent care provision of the Affordable Care Act (ACA), which allows young adults to stay on their parent's policy until age twenty-six, extends beyond the realm of health insurance coverage and increases human capital investment. In particular, the ACA has likely caused a 3–5 percent increase in college enrollment among women twenty-three to twenty-five years of age. The authors reached this conclusion through a difference-in-difference research design that uses American Community Survey data. Interestingly, the authors did not find a robust educational effect for men. Prior to the ACA, insurance companies could charge women higher premiums than men of the same age. The authors argue that the ACA dependent coverage has reduced the opportunity cost of attending school full time more for young women than for young men. The broader lesson is that the long-run benefits of health insurance expansions may be larger than expected and that the ACA may play an important, if unanticipated, role not only in improving individuals' short-run finances, mental health, and physical well-being but also in decreasing inequality and improving social welfare over time.
Our second article, by Katrina Kimport, Nicole E. Johns, and Ushma D. Upadhyay, evaluates the impact of controversial state laws requiring abortion patients to view their ultrasounds images. Critics argue that such mandates are intended to constrain how women make personal decisions about their bodies and parenthood, but there has been relatively little analysis of the actual consequences of these laws. Focusing on Wisconsin's mandated ultrasound viewing law, the authors used patient chart data before and after the law went into effect and in-depth interviews with women to explore how the law impacted patients' viewing decision making. They found that implementation of the mandatory viewing law dramatically increased the viewing rate from 62 percent to 92 percent, with larger impacts on viewing behavior for black women than for white women. Overall, the study encourages attention to the coercive power of laws regulating abortion and the need to investigate not only how they affect individuals' behavior and experience but also which citizens are impacted.
In the third article, Colleen L. Barry, Sachini Bandara, Kimberly T. Arnold, Jessie K. Pintor, Laura M. Baum, Jeff Niederdeppe, Pinar Karca-Mandic, Erika Franklin Fowler, and Sarah E. Gollust assess the content of television health insurance advertising during three open enrollment periods of the ACA between 2013 and 2016. They found that the most common information messages focused on plan choice and availability of low-cost plans, but messages shifted over enrollment cycles to emphasize avoidance of tax penalties and availably of financial assistance. These advertising approaches make sense in the context of efforts to persuade individuals to enroll in marketplace plans. At the same time the dramatic decline over time in explicit mentions of the ACA and Obamacare may help explain why many citizens fail to understand the connection between the actions of government and the benefits they are receiving.
The first three research articles in this issue use social science methods to retrospectively evaluate the character and effects of public actions. But in a democracy, policy makers are expected to answer almost immediately for the things they have done. It is rarely sufficient for leaders to say, “just wait and see” or “judge the policy by the study we will carry out in five years.” Superiors, sovereigns, and the public at large want to know—and believe they have a right to know—the reasons why policy makers have taken (or not taken) particular actions. As Robert E. Goodin argues in our fourth essay, there are many different reasons for giving reasons, which can be distinguished and categorized along two dimensions: political moralism versus political realism, and high versus low politics. Goodin shows that all of these were in play in the debate over the enactment of the ACA and that the attempts at repealing President Obama's health reform were characterized by low-politics and political-realist modes of reason giving almost exclusively.
In our Beneath the Surface essay, distinguished health policy scholar Theodore R. Marmor unpacks the concept of social insurance. Marmor provides a timely reminder of what makes social insurance social—and why social insurance is so important to American political life. He clarifies the crucial differences between social and commercial insurance, as well as between social insurance and government social assistance programs with means-tested eligibility standards. Marmor's historically informed essay stresses the need for Americans to relearn the appeal of social insurance principles and offers lessons into current debates surrounding both conservative assaults on Social Security pensions and progressive proposals to establish either “Medicaid for all” or “Medicare for all.”
Finally, Steven B. Spivack, Miriam J. Laugesen, and Jonathan Oberlander in our special section “The Politics and Policy of Health Reform” analyze the politics of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which abolished the long-reviled Sustainable Growth Rate (SGR) under Medicare. MACRA was enacted with broad bipartisan majorities and hailed as a major achievement. However, the authors argue that, now that SGR is gone, health policy actors are beginning to face up to the administrative, technical, and political realities of its replacement. There is growing disillusionment with the law's value-based purchasing agreements and uncertainty over their sustainability. While the SGR is gone, political contestation over physician payment will clearly continue.
Taken together, the essays in this issue demonstrate why health policy researchers need to address following five fundamental questions: What health policies are being implemented in a given polity? What are the intended effects of such policies? Goals and aspirations aside, what are the policies' real-world consequences? What groups bear the attendant costs and benefits? Finally, how do policymakers justify their decisions to create, maintain, amplify, or dampen these outcomes? Providing empirically grounded and normatively compelling answers to these questions is JHPPL's scholarly mission.