The public is an important stakeholder in health policy. A vast literature explores how the public thinks about health matters, whether attitudes toward health policy mirror those in other policy domains, and whether government health policy making is responsive to public sentiment (for a thoughtful review, see Schlesinger 2013). Typically, the relationship between health policy and public attitudes is subtle, complex, and multistaged. Most health policy decisions are made by government officials. While leaders are certainly aware of public attitudes on health care (as expressed in opinion polls), they may not possess a political incentive or capacity to follow them. As long as politicians avoid taking actions that a large segment of the public strongly opposes, they may possess the discretion to implement whatever policies they want.
For its part, the public tends to be poorly informed about the details of health policy. Citizens lead busy lives and do not have the time to devote their attention to public affairs. As a result, they tend to rely on political elites and “heuristics” (such as partisan cues) to reach judgments about health policy. Yet in certain cases the relationship between public attitudes and health policy is potentially much closer. The articles in this issue examine several of these cases, focusing on the ways that the public may directly shape health policy—or be directly shaped by it.
One way that the public can directly influence health policy is by voting on ballot initiatives on proposed changes to health care programs. In our first article, David A. Matsa and Amalia R. Miller take a close look at Maine's 2017 referendum on Medicaid expansion. The authors merged election results from localities across the state to identify the characteristics of areas that supported expansion. They found a strong relationship between Medicaid vote share and educational attainment—places with a higher share of the population with at least a bachelor's degree were more supportive of Medicaid expansion, even after controlling for income. Their study also suggests that interests matter: areas with more uninsured individuals and greater hospital employment were more supportive of expansion, whereas areas populated by more nonhospital providers (whose incomes might decrease from expansion if it crowds out higher-paying private insurance) were less supportive. The authors used the Maine results to predict the outcomes of hypothetical ballot initiatives on Medicaid expansion in other states. They found that ballot initiatives (if they were allowed to go forward—something that would require a change in the laws of some states) would be likely to pass in 5 of the 18 states that had not expanded Medicaid at the time of Maine's vote. While this exercise is speculative, it does suggest that direct democracy could be a mechanism to expand the social safety net.
While referenda allow the public to express its views on health policies, the implementation of health policies may have the potential to change public opinion in an era when partisanship is a primary determinant of public attitudes toward government. In our second article, Adrienne Hosek used longitudinal data from the American Life Panel to follow the same individuals repeatedly over the first year of Affordable Care Act (ACA) implementation. Hosek found that opinions of the ACA among individuals who enrolled in insurance plans on the marketplaces improved in the few months between the start and close of open enrollment among both Democrats and Republicans. She also found that individuals who resided in states that did not expand Medicaid and who failed to obtain insurance developed significantly more negative opinions of the ACA. These findings suggest that health care is not an abstraction for Americans—it impacts their material well-being and sense of security, and these effects can change people's attitudes even in an age of polarization.
Another direct connection between public beliefs and health policy arises when patients and citizens participate in key health care decision-making processes. In our third research article, Katherine Boothe used interviews and data from reports and hearings to examine how participation in Canadian drug assessment committees (which make recommendations about which drugs should be reimbursed by various public drug insurance plans) affects the beliefs of different kinds of participants with respect to health technology assessment and the benefit of public and patient involvement. She found that the degree and content of ideational change varied by participant type. In particular, her study reveals an increase in Canadian patient groups' acceptance of the principles of health technology assessment (which may reflect a learning process as lay persons gain a closer view of how the process works) but less change in the ideas of technical members of drug assessment committees.
In another piece on health policy outside the United States, Claus Wendt's “Beneath the Surface” essay looks at the current status of social health insurance programs in five European nations. He examined the impact of privatization and competition policies and whether these programs are experiencing a crisis of trust or loss in support among the public. Wendt found that, while costs and cost-sharing burdens have increased, public support for European social health insurance has not been declining. Indeed, the traditional value of solidarity has even been strengthened over the past few decades.
Finally, in the issue's “Politics and Policy of Health Reform” essay, Petra W. Ramussen and Gerald F. Kominski examine the success of California's individual marketplace under the ACA, which today covers some 1.3 million consumers. The authors argue that California's success reflects a variety of political, organizational, and technical design factors, including proactive outreach programs to encourage enrollment, a high level of stakeholder enragement, and innovative approaches to stabilize the market in the face of uncertainty.
Over the past several years, JHPPL has published a number of articles that explore the role of the public in the health care arena. The articles in the current issue add materially to our knowledge by highlighting the diverse roles that members of the public play as voters, patients, participants, and evaluators of the performance of public and private health care systems. While interest groups and policy elites exercise tremendous influence over how health care is organized, delivered, and financed, the articles in this issue also provide an important reminder that the public is the most important stakeholder in health policy and that scholars need to attend carefully to its behavior and views.