As I write in March 2019, the major national health policy issue is whether the Democratic Party will support “Medicare for All” as the next stage in the long struggle for universal coverage in the United States. JHPPL has already published essays that touch on this important topic, such as Paul Starr's 2018 essay “Rebounding with Medicare: Reform and Counterreform in American Health Policy.”
Yet we are not in the post–Affordable Care Act era quite yet. While the ACA survived the attempts by congressional Republicans and the Trump administration to repeal it, struggles over the law's implementation continue. The Trump administration not only has repeatedly argued that Obamacare is collapsing of its own weight but also has used its executive powers to reduce efforts to encourage people to sign up for ACA plans and weaken enforcement of ACA regulations. While even sympathetic observers would acknowledge that the ACA is not working perfectly, bipartisan support for reforms has not been forthcoming. Health policy scholars thus have strong reasons to keep monitoring the ACA's development, with an eye to the law's impact and consequences for the politics of health policy making.
In our first article, David Anderson and Paul Shafer examine whether the Trump administration's political messaging against the reform and advertising reductions had an effect on Health Insurance Marketplace enrollment nationwide. The authors used difference-in-differences and event-study models with weekly county-level data to estimate the incremental enrollment loss in the postinauguration period. Their models identify significant decreases (between 24% and 30%) in marketplace applications submitted during the weeks after the inauguration of President Trump in 2017 relative to 2016. The results show that, despite no changes in plan availability or pricing, the transition of power to the Trump administration had an immediate and sizable negative impact on ACA enrollment activity.
One of the most important design features of the ACA is that it gave states discretion over key implementation decisions, such as whether to establish and how to structure a state health insurance marketplace. How people experience the ACA thus depends in part on the state in which they live. Our second article, by Julianna Pacheco and Elizabeth Maltby, looks at how the state-level implementation environment has mediated public support for the ACA. The authors analyzed quarterly opinions toward the ACA by state between 2009 and the start of the 2016 presidential election, focusing on general favorability toward the ACA, beliefs about the law's impact on the country and one's family, understanding of the law's effects, and support for keeping or expanding the law. The authors found that public support for the ACA increased following gubernatorial announcement of the creation of a state-based marketplace, which gave states more control over health care reform, but that the adoption of federal or partnership marketplaces had essentially no effect on public opinion and in some cases reduced positive perceptions.
In our final research article, Denis G. Arnold and James L. Oakley examine the behavior of the pharmaceutical industry. The context for the study is the exposure of children and adolescents to erectile dysfunction (ED) commercials on television. In a previous study published in JHPPL (Arnold and Oakley 2013), the authors demonstrated that the pharmaceutical industry had failed to live up to its own standards for shielding children from broadcast advertising campaigns for ED drugs. These standards call for ads to be broadcast only to audiences that are 90% adult. The earlier JHPPL investigation found that for no quarter during the 4-year period of study did any ED brand satisfy the audience composition threshold set forth in the industry's own standards. These results received wide coverage in the media and were acknowledged by both individual companies and the industry's trade association. In their new study, Arnold and Oakley examine how the pharmaceutical industry has responded to public disclosure of its noncompliance with its own guiding principles. Broadly, they found that public disclosure did not cause firms to alter their behavior, suggesting that the pharmaceutical industry is simply not willing to police itself. The authors conclude that policy changes will be needed to compel or incentivize industry compliance.
Finally, in an article in our Politics and Policy of Health Reform section, Sujoy Chakravarty, Kristen Lloyd, Jennifer Farnham, and Susan Brownlee examine the implementation of the Delivery System Reform Incentive Payment (DSRIP) program in New Jersey, one of several current policies designed to achieve greater value and efficiency in the provision of health care services. Based on a hospital survey and stakeholder interviews, they found that DSRIP is achieving its primary goal to tie receipt of Medicaid supplementary payments to quality and reporting of care but that implementation has not shown sensitivity to the specific constraints, priorities, and resource needs of safety net hospitals.
Taken together, these articles offer key empirical insights into the continuing influence of both private industry and political institutions such as federalism and the presidency in structuring the US health policy landscape. Health reformers will need to take these factors into account whether they are seeking to preserve the ACA or to move beyond it.