Give the people less, and make them thank you for it. It’s an odd electoral strategy, but a new study suggests it’s one way to explain the outcome of the 2016 election.
The paper argues that “intentional efforts by Republicans to sabotage the implementation of the health-care law” caused real dissatisfaction among voters. But according to polls, faced with constant media coverage of rising prices, voters responded by supporting Republican politicians who promised to repeal and replace Obamacare. That dynamic, it suggests, could very well have given Donald Trump the presidency. And the same mechanisms could be at play in 2018 and beyond.
The study, posted to the online repository SSRN by the Ohio State University researchers Vladimir Kogan and Thomas Wood, has not yet been published in a peer-reviewed journal, and is unusually provocative and firm in its conclusions. But the paper relies on popular polls like the Kaiser Family Foundation tracking poll, and its broad argument aligns with the conclusions of writers like my colleague Olga Khazan that public opinion about Obamacare and premiums had something to do with Trump’s victory, even as it makes that case more forcefully. “The implementation of Obamacare,” its authors write, “may have indeed cost Hillary Clinton the presidency.”
Kogan and Wood’s paper provides a mechanism to explain that outcome. The authors found that increased coverage under Obamacare was generally associated with support for Democratic presidential candidate Hillary Clinton, holding all else equal. But things got more complicated when costs were considered, because as Kogan and Wood write, “premium increases moderated the political impact of exchange enrollment.” At both the county level and the individual-voter level, support for Trump was correlated with increases in premiums among people who self-purchased private plans—both on and off the exchanges—and those on Medicaid. There was not a similar correlation between support for Trump and premium increases among people with employer-sponsored plans.
In places where premiums rose for private-exchange plans, even the people who gained heavily subsidized or free coverage under the new law became more likely to support Trump.
Judging the candidates by their rhetoric, that would seem to make a certain degree of sense. Premiums skyrocketed in many exchange markets over 2015 and 2016, and one of Trump’s most frequent campaign promises was to reduce those premiums by repealing Obamacare.
But rising premiums on the exchanges did not mean that most Americans faced correspondingly large drains on their wallets. Those premiums only applied to people buying plans on the exchanges—the smallest piece of the insurance pie—and even then, some 85 percent of them received subsidies, shielding them from some or all of the increase in costs. That makes it hard to credit the notion that price pressures alone drove voters toward Trump.
The hypothesis put forward by Kogan and Wood is that overzealous and inaccurate coverage of premium increases by media outlets was largely responsible for boosting support for Trump. “Our results suggest that consumers were influenced not by the individual premiums they would have seen when logging in to renew their coverage,” they wrote, “but rather the coverage of the issue in the local press, which focused largely on the non-discounted rates.” The study doesn’t cite specific instances of such coverage. But when Aetna announced it would exit exchanges in 11 states in August of 2016, for example, much of the coverage focused on rising costs, often without specifying just whose premiums were increasing and how that actually affected costs for individual consumers.
If this hypothesis holds, it would confirm the fears of Kaiser Family Foundation president Drew Altman, who wrote in a July 2016 column in TheWall Street Journalthat poor reporting about pre-discount premium increases led people to believe that their own out-of-pocket costs were increasing. “People may read news stories on premium increases as validating criticisms they have heard about the ACA,” Altman wrote. Eighty percent of the people in that month’s Kaiser Family Foundation tracking poll had seen reports on premium increases, and over two-thirds of those falsely believed that the increases applied to all plans or just to employer-based coverage. Poll respondents also consistently overestimated premium spikes, mistaking the highs reported for average increases, which in major cities hovered around 10 percent.
The second piece of Kogan and Wood’s argument is that premium increases would likely have been smaller without what they term Republican “sabotage,” and that the sabotage also affected the election independent of information gaps. The first part is almost certainly right. A campaign by Republican legislators to block market-stabilizing provisions and payments to insurers, block all legislation designed to tweak the health-care law, and promise a full repeal of the bill in 2016 almost certainly contributed to market instability in the exchanges and rising premiums.
Additionally, Republican governors have mostly been slow to expand Medicaid coverage to low-income residents of their states or have declined to do so at all, decisions that have both decreased the number of potentially satisfied Clinton voters with new coverage and further destabilized markets and prices. The study finds that had Georgia, Florida, North Carolina, and Wisconsin embraced Medicaid expansion or even pursued slightly less-obstructionist policies, it could very well have tipped those states—and the 2016 election—to Clinton.
The usefulness of such counterfactual analysis is limited. But it does suggest a link between health care and voting that experts have long observed. A series of election studiesby Harvard researcher Robert Blendon illustrates that while health care isn’t always a major factor in elections, in the cycles when it does rise to be a top priority for many voters, dissatisfaction with costs is the main driver of their decisions. Notably, it doesn’t really matter if voters’ personal costs have really increased; what matters is that they believe prices are rising.
With those elements in place, the Republican strategy to dismantle Obamacare can appear cunning in retrospect. While there was certainly a substantial natural backlash to the Affordable Care Act, GOP policy appears to have amplified that opposition. The refusal of many Republican governors to expand Medicaid—especially in states with major populations of people of color—kept millions of potential Democratic voters from the aegis of coverage. At the same time, a suite of actions that destabilized the marketplaces helped raise the prices. Then—aided by superficial coverage in the press—Republican candidates in 2016 were able to run a coordinated campaign reinforcing the perception that Obamacare had introduced runaway costs. And they won.
The truth is probably less Machiavellian. Health care is complicated, and in this media landscape misinformation and disinformation thrive and can help candidates, whether intentionally or not. And the Obama administration notably failed to inform millions of citizens about their benefits and rights under its signature program, or to persuade them of that program’s successes, ceding more ground in turn to misinformation.
Where this leaves politicians in 2018 and beyond is an open question. It seems certain rising premiums and misinformation will continue to be features of the political landscape. Republicans appear intent on blocking reforms to Obamacare, and pushing for full repeal, even though those acts serve to destabilize markets.
The question is, with Republicans now in control of Congress and the White House, will voters still trust them to lower costs, or will they assign them responsibility for rising prices?