One of the intellectual strengths of JHPPL is its multidisciplinary orientation. At a time when the social and behavioral sciences are becoming hyperspecialized and increasingly focused on narrow research questions, JHPPL continues to publish creative, high-quality articles of broad significance by scholars who bring to their work the ideas, tools, and methods of a wide variety of disciplines and research traditions. This issue showcases the impressive range of JHPPL authors. It contains articles written by economists, marketing professors, professors of medicine, and political scientists. All of the articles are focused on significant health politics and policy topics, take seriously the institutional and political complexity of real-world governance, and are written in a way that is accessible to a broad audience.
In our lead article, Helen Levy, John Z. Ayanian, Thomas C. Buchmueller, Donald R. Grimes, and Gabriel Ehrlich examine one of the most important current health policy questions facing state policy makers—what is the fiscal impact of Medicaid expansion? A growing body of research has documented the benefits of Medicaid expansion for new beneficiaries, including increased financial security. However, the impact of Medicaid expansion on a state's fiscal bottom line remains unclear. Some governors who have declined to implement Medicaid expansion have argued that the economic benefits to their states are less than advocates claim. While the direct budgetary effects of Medicaid expansion are relatively straightforward for state budget agencies to calculate, determining the magnitude of the dynamic economic spillover effects of Medicaid expansion (such as how much it will increase economic activity in the state, and how much additional state tax revenue this new activity will generate) is a thorny issue. The authors make a significant contribution to this literature by examining Michigan as a case study. They use a sophisticated macroeconomic model to project the state fiscal impact of Michigan's Medicaid expansion through 2021. Taking into account complex, macroeconomic feedbacks, they find that Medicaid expansion in Michigan yields clear fiscal benefits for the state that exceed the state's costs in every year. The methods used in the article could in principle be used by policy makers in other states to determine the fiscal impact of Medicaid expansion.
In our next article, Matthew D. Meng and Roberta N. Clarke address another pressing health policy issue—the large number of people on organ donation waiting lists who need an organ in order to survive. Twenty Americans die each day for lack of an organ. The main approach to increasing the number of organ donors in the US has been to appeal to altruism, relying on people's intrinsic motivation to give “the gift of life” to others. However, altruistic appeals have not succeeded in closing the gap between the demand for and supply of donated organs. One possible strategy to increase donation rates is to give priority to those who register as an organ donor over those who have not registered. However, a concern is that the approach could backfire because providing extrinsic rewards can sometimes reduce the target behavior among people who are altruistically motivated. To determine what impact the approach would have in practice, the authors perform two online behavioral experiments on participants recruited from across the nation. The authors find that giving people who register priority could indeed increase overall registration rates. The extrinsic reward has a significant, positive effect on motivating people who are more self-interested to become organ donors, but does not crowd out donations among those who are more altruistically inclined. According to the authors, the approach appears to work by inducing a sense of “anticipated regret,” which can push people to overcome the common obstacles to registration.
The next two research articles explore the political dimensions of contemporary health policy issues. One of the most fascinating recent developments at the state level has been the growing use of the ballot initiative process to change public policy with respect to the legalization of cannabis. What factors explain voter support and likelihood of passage of these measures? To address these questions, Daniel G. Orenstein and Stanton A. Glantz examine the role of campaign contributions, demographics and other factors in the outcomes of 32 cannabis decriminalization, medical legalization, and recreational legalization ballot initiatives from 2004 to 2016. Of the 32 initiatives, 3 were focused on decriminalization, 15 targeted medical use, and 14 were focused on recreational use. Eighteen succeeded and 14 failed. Based on their statistical analysis of the outcomes, the authors find that initiative year, voter turnout, and population born before 1946 were significantly associated with voter support for the initiatives. While the authors found an association between funding advantage and likelihood of initiative passage, overall their findings do not support the conclusion that campaign funding is the dominant factor in legalization initiative success.
In the final research article in this issue, Samuel Trachtman examines the politics of Affordable Care Act (ACA) marketplace implementation at the state level. State politics has become increasingly nationalized and polarized in recent years, yet state lawmakers face pressure to focus on producing benefits for their constituents. What happens when partisan incentives and pragmatic politics come into conflict? Republican lawmakers in particular have been cross-pressured by their constituents' interest in well-functioning marketplaces and their party's interest in undermining the ACA. Trachtman looks at three key dimensions of marketplace implementation—navigator laws, transition plan termination, and rating area configurations. He shows, first, that partisan control matters: Democrat-controlled states have been more likely to bolster marketplaces than Republican-controlled states have. He further shows that the activities of federated ideological groups also make a difference. With respect to navigator laws, where Republicans have been most cross-pressured, marketplace erosion has been more common in the states where conservative political networks have been strongest.
In our “Beneath the Surface” essay, Katherine Farrow, Gilles Grolleau, and Naoufel Mzoughi take a critical look at health messaging interventions that seek to persuade people to give up unhealthy habits like smoking and take up healthier behaviors such as exercising and eating a balanced diet. The authors argue that the efficacy of these type of communication efforts can be marginal, in part because the interventions make three well-intentioned but mistaken choices in their commination strategies. The first common mistake is normalizing an undesirable behavior (such as binge drinking) by emphasizing its prevalence, which can paradoxically make people less likely to change their unhealthy behavior in order to conform to social norms and behave the same way that other people do. The second mistake is to emphasize the large number of victims of detrimental behaviors, which can lead to “psychic numbing” or the collapse of compassion in the face of the overwhelming scale of the problem. The final mistake is to give people too many reasons to encourage behavioral change, which can paradoxically reduce the overall persuasiveness of a message. All three mistakes reflected a flawed intuition that “more is better,” which can undermine the very improvements in health behaviors the interventions are intended to encourage.
Finally, in our “Tracking Health Reform” section, Emma Sandoe and Ezra Golberstein discuss Medicaid Buy-In policies which are at the forefront of many state health reform efforts. They clarify the implications of key design choices that policy makers will need to make on four major issues—whether plans are sold on or off exchange, whether plans are run by the state or a Medicaid Managed Care Organization, who is eligible to purchase plans, and which benefits will be covered and at what payment rates.
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This is my last note as editor. I have enjoyed the opportunity to work with so many talented authors and reviewers from a wide variety of backgrounds and disciplines, and I know JHPPL's intellectual pluralism will continue under the next editor, Jonathan Oberlander. In closing, I'd like to take this opportunity to thank Jennifer Costanza for her outstanding work the past three years as managing editor. I would also like to thank our publisher Duke University Press, the JHPPL associate editors, and the Watson Institute for International and Public Affairs at Brown University for hosting the journal and providing excellent office space.