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Health Insurance Loss during COVID-19 Increases Support for Universal Health Coverage
Abstract
Context:
The United States is the only high-income country that relies on employer-sponsored health coverage to insure a majority of its population, and millions of Americans lost employer-sponsored health insurance during the COVID-19-induced economic downturn. We examine public opinion toward universal health coverage policies in this context.
Methods:
Through a survey of 1,211 Americans in June 2020, we examine the influence of health insurance loss on support for Medicare for All (M4A) in two ways. First, we examine associations between pandemic-related health insurance loss and M4A support. Second, we experimentally prime some respondents with a vignette of a sympathetic victim losing employer-sponsored coverage during COVID-19. As a secondary outcome, we examine the effect of these exposures on support for the Affordable Care Act.
Findings:
We find that directly experiencing recent health insurance loss is strongly associated (10 pp, p<0.01) with greater M4A support. Experimental exposure to the vignette increases M4A support by 6 pp (p=0.05). When expansion of the ACA is added as a response option, experimental priming still increases support for M4A, but direct experience of insurance loss is associated with greater support for the ACA than for M4A.
Conclusions:
In the context of the COVID-19 pandemic, situational framings can induce modest change in support for M4A, especially among individuals without well-formed preferences. However, real-world health insurance losses are associated with larger differences in support for M4A and with greater support for existing safety net policies such as the ACA. The large-scale loss of employer-based insurance during COVID-19 offers the potential for new structural coalitions supportive of universal coverage.
... The COVID-19 pandemic has elicited strong (shared) perceptions of risk, both about health and the economy, and these risk perceptions have been shown to influence a variety of social attitudes (24). Previous research has shown that experimentally manipulating threats to healthcare increased political liberalism (25) and that experiencing the loss of employment/health insurance was associated with support for UHC (26,27). ...
Introduction
The multiple risks generated by the COVID-19 pandemic intensified the debate about healthcare access and coverage. Whether the burden of disease caused by the coronavirus outbreak changed public opinion about healthcare provision remains unclear. In this study, it was specifically examined if the pandemic changed support for governmental intervention in healthcare as a proxy to support for universal health coverage (UHC). It also examined which psychological factors related to the socioeconomic interdependence exposed by the pandemic may be associated with a potential change.
Methods
Online survey data was collected over 18 months (from March 2020 to August 2021) across 73 countries, containing various social attitudes and risk perceptions related to COVID-19. This was a convenience sample composed of voluntary participants (N = 3,176; age 18 years and above).
Results
The results show that support for government intervention in healthcare increased across geographical regions, age groups, and gender groups (an average increase of 39%), more than the support for government intervention in other social welfare issues. Factors related to socioeconomic interdependence predicted increased support for government intervention in healthcare, namely, social solidarity (ß = 0.14, p < 0.0001), and risk to economic livelihood (ß = 0.09, p < 0.0001). Trust in the government to deal with COVID-19 decreased over time, and this negative trajectory predicted a demand for better future government intervention in healthcare (ß = −0.10, p = 0.0003).
Conclusion
The COVID-19 pandemic may have been a potential turning point in the global public support for UHC, as evidenced by a higher level of consensus that governments should be guarantors of healthcare.
... This is consistent with recent work showing limited effects of the pandemic on attitudes (Ares, Bürgisser, and Häusermann 2021;Blumenau et al. 2021;Lowande and Rogowski 2021). However, our findings differ from those from studies of the US, which have shown an increase in support for the expansion of governmentprovided healthcare coverage and spending among those most exposed to the pandemic (Fox et al. 2022;Rees-Jones et al. 2022). This very likely reflects a key difference between the universal healthcare system of the UK and the employer-sponsored insurance system of the US, rather than an inherently conflicting set of findings. ...
The onset of the COVID-19 pandemic constituted a large shock to the risk of acquiring a disease that represents a meaningful threat to health. We investigate whether individuals subject to larger increases in objective health risk -- operationalised by occupation-based measures of proximity to other people -- became more supportive of increased government healthcare spending during the crisis. Using panel data which tracks UK individuals before and after the outbreak of the pandemic, we implement a fixed-effect design which was pre-registered before the key treatment variable was available to us. While individuals in high-risk occupations were more worried about their personal risk of infection, and had higher COVID death rates, there is no evidence that increased health risks during COVID-19 shifted attitudes on government spending on healthcare, nor broader attitudes relating to redistribution. Our findings are consistent with recent research demonstrating the limited effects of the pandemic on political attitudes.
... This is consistent with recent work showing limited effects of the pandemic on attitudes (Ares, Bürgisser and Häusermann 2021; Blumenau et al. 2021; Lowande and Rogowski 2021). However, our findings differ from those of studies of the United States, which have shown an increase in support for the expansion of government-provided healthcare coverage and spending among those most exposed to the pandemic (Fox et al. 2022;Rees-Jones et al. 2022). This very likely reflects a key difference between the universal healthcare system of the UK and the employer-sponsored insurance system of the United States, rather than an inherently conflicting set of findings. ...
The onset of the COVID-19 pandemic constituted a large shock to the risk of acquiring a disease that represents a meaningful threat to health. We investigate whether individuals subject to larger increases in objective health risk – operationalized by occupation-based measures of proximity to other people – became more supportive of increased government healthcare spending during the crisis. Using panel data that track UK individuals before (May 2018–December 2019) and after (June 2020) the outbreak of the pandemic, we implement a fixed-effect design that was pre-registered before the key treatment variable was available to us. While individuals in high-risk occupations were more worried about their personal risk of infection and had higher COVID-19 death rates, there is no evidence that increased health risks during COVID-19 shifted either attitudes on government spending on healthcare or broader attitudes relating to redistribution. Our findings are consistent with recent research demonstrating the limited effects of the pandemic on political attitudes.
Health shocks may drive the public to support policies and candidates that protect health and well-being. Did the COVID-19 pandemic, as one such shock, shift preferences for health reform in the United States? Using nationally representative surveys of over 70,000 US adults between 2019 and 2020, we find that experiences with COVID-19—measured at both the individual and community levels—increased support for Medicare for All by multiple percentage points. Consistent with partisan entrenchment on health issues, independents and weak partisans drove the association at the individual level; these subgroup differences were not observed for community-level experiences. To reduce concerns about confounding, we use data from multiple points in time to establish the expected temporal relationship between experiences with COVID-19 and support for health reform. Finally, consistent with the importance of health issues in the 2020 presidential race, we find that changes in support for health reform were mirrored by a comparable shift in support away from the incumbent, President Trump, in the weeks leading up to the election. Even if short lived, these shifts may have influenced both the discourse and outcome of the election.
Policy Points A decade after failing to make it into the Affordable Care Act, the public option reemerged as a health reform goal at both the national and state levels, with polls reporting strong, bipartisan support. A 2020 poll that probed both support for one public option approach (Medicare "buy-in") and attitudes toward government suggests that differences in these attitudes could plague reform advocates' efforts. Although the COVID-19 pandemic viscerally highlighted the need for a more coherent health care system-including universal coverage-other recent evolutions in the broader US political context could undermine reform.
Objective
To conduct a polling experiment to understand the possible framing effects that drive constituents’ views around Medicare For All (MFA) and Medicaid Buy‐In (MBI).
Data Sources and Study Setting
Five thousand and fifty‐one US adults aged 18 and older were recruited to participate in an online poll conducted between September 12, 2018, and September 26, 2018.
Study Design
Participants were randomized to receive one of four polls: (a) a poll measuring respondent approval for MFA, with the name of the proposal stated with a description; (b) a poll measuring approval for MFA, with only a description of the proposal; (c) a poll measuring approval for MBI, with the name stated with a description; or (d) a poll measuring approval for MBI, with only a description.
Principal Findings
Including the names “Medicare For All” and “Medicaid Buy‐In” increases approval by 3.4 (from 32.7 percent to 36.1 percent) and 5.0 (from 50.1 percent to 55.1 percent) percentage points, respectively. Support varies by age, where MBI is most strongly supported by Millennials, while Baby Boomers and those older than 65 are more likely to support MFA.
Conclusions
Constituents are more likely to support a proposal when given the names of the proposal. Approval is also higher for health policies that are framed as expansions of existing policies than as new programs.
Research on stasis or change in public opinion toward health, health policy, and medical care tends to focus on short-term dynamics and to emphasize the impact of discrete messages communicated by individual speakers in particular situations. This focus on what we term "situational framing," though valuable in some respects, is poorly equipped to assess changes that may occur over the longer term. We focus, instead, on "structural framing" to understand how institutionalized public health and health care policies impact public opinion and behavior over time. Understanding the dynamics of public opinion over time is especially helpful in tracking the political effects of the Patient Protection and Affordable Care Act of 2010 as it moves from the debate over its passage to its implementation and operation.
We argue that the United States does not have comprehensive national health insurance (NHI) because American political institutions are biased against this type of reform. The original design of a fragmented and federated national political system serving an increasingly large and diverse polity has been further fragmented by a series of political reforms beginning with the Progressive era and culminating with the congressional reforms of the mid-1970s. This institutional structure yields enormous power to intransigent interest groups and thus makes efforts by progressive reformers such as President Clinton (and previous reform-minded presidents before him) to mount a successful NHI campaign impossible. We show how this institutional structure has shaped political strategies and political outcomes related to NHI since Franklin D. Roosevelt. Finally, we argue that this institutional structure contributes to the antigovernment attitudes so often observed among Americans.
Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an "integrator") that accepts responsibility for all three aims for that population. The integrator's role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.
EUROPEAN GOVERNMENTS REDISTRIBUTE income among their citizens on a much larger scale than does the U.S. government. European social pro- grams are more generous and reach a larger share of citizens. European tax systems are more progressive. European regulations designed to protect the poor are more intrusive. In this paper we try to understand why. The literature on the size of government is rich and varied. However, here we do not focus on the size of government as such, but rather on the redistributive side of government policies. Thus our goal is in one sense narrower than answering the question, "What explains the size of govern- ment?" since we focus on a single, but increasingly important, role of fis- cal policy. Yet in another sense our focus is broader, because redistributive policies go beyond the government budget—think, for instance, of labor market policies. We consider economic, political, and behavioral explanations for these differences between the United States and Europe. Economic explanations focus on the variance of income and the skewness of the income distribu- tion before taxes and transfers, the social costs of taxation, the volatility of income, and expected changes in income for the median voter. We con- clude that most of these theories cannot explain the observed differences.
Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency—and the sitting president—have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs.
Analogies have captivated philosophers for millennia, yet their effects on modern public opinion preferences remain largely unexplored. Nevertheless, the lack of evidence as to whether analogies aid in political persuasion has not stopped politicians from using these rhetorical devices in public debates. To examine such strategic attempts to garner political support, we conducted survey experiments in the United States that featured the analogical arguments being used by Democrats and Republicans as well as some of the policy rationales that accompanied their appeals. The results revealed that analogies—especially those that also provided the underlying policy logic—increased support for individual health coverage mandates, the Affordable Care Act (ACA), and even single payer national health proposals. However, we demonstrated that rebutting flawed analogies was also possible. Thus, within the health care arena, framing proposals with analogies can alter policy preferences significantly, providing a way to deliver policy rationales persuasively.
Policy Points
• “Medicare for All” is an increasingly common term in US health care reform debates, yet widespread confusion exists over its meaning.
• The various meanings of Medicare for All and other related terms reflect divergent political and philosophical assumptions about the preferred direction of health care reform, as well as the hybrid structure of the current Medicare program.
This article examines online recruitment via Facebook, Mechanical Turk (MTurk), and Qualtrics panels in India and the United States. It compares over 7300 respondents—1000 or more from each source and country—to nationally representative benchmarks in terms of demographics, political attitudes and knowledge, cooperation, and experimental replication. In the United States, MTurk offers the cheapest and fastest recruitment, Qualtrics is most demographically and politically representative, and Facebook facilitates targeted sampling. The India samples look much less like the population, though Facebook offers broad geographical coverage. We find online convenience samples often provide valid inferences into how partisanship moderates treatment effects. Yet they are typically unrepresentative on such political variables, which has implications for the external validity of sample average treatment effects.
What is the effect of democratic competition on the power of elites to frame public opinion? We address this issue first by defining the range of competitive contexts that might surround any debate over a policy issue. We then offer a theory that predicts how audiences, messages, and competitive environments interact to influence the magnitude of framing effects. These hypotheses are tested using experimental data gathered on the opinions of adults and college students toward two policy issues—the management of urban growth and the right of an extremist group to conduct a rally. Our results indicate that framing effects depend more heavily on the qualities of frames than on their frequency of dissemination and that competition alters but does not eliminate the influence of framing. We conclude by discussing the implications of these results for the study of public opinion and democratic political debate.
Citizens, especially those who are knowledgeable and care the most about politics, are motivated to defend their beliefs and attitudes in the face of discrepant information. These motivated biases strongly influence the way people think about health care policies and the politicians and parties that propose or attack these contentious policies. Three cognitive mechanisms are identified: a prior belief effect, confirmation bias, and disconfirmation bias. Together, these information processes conspire to produce persistence and polarization of opinion on health care policies.
This study assesses the relationship between political partisanship and attitudes and behavior with respect to the H1N1 virus (swine flu) crisis of 2009 in general, and the U.S. mass vaccination program in particular. I argue that even seemingly nonpartisan political issues like public health are increasingly characterized by partisan polarization in public attitudes and that such polarization is attributable, at least partly, to the breakdown of the information commons that characterized the U.S. mass media from roughly the 1950s until the early 1990s. In its place has arisen an increasingly fragmented and niche-oriented media marketplace in which individuals are better able to limit their information exposure to attitudes and opinions that reinforce, rather than challenge, their preexisting beliefs. I test my argument against a variety of data sources, including opinion surveys and state-level swine flu vaccination rate data.
In this innovative account of the way policy issues rise and fall on the national agendaâthe first detailed study of so many issues over an extended periodâFrank R. Baumgartner and Bryan D. Jones show that rapid change not only can but does happen in the hidebound institutions of government. Short-term, single-issue analyses of public policy, the authors contend, give a narrow and distorted view of public policy as the result of a cozy arrangement between politicians, interest groups, and the media. Baumgartner and Jones upset these notions by focusing on several issuesâincluding civilian nuclear power, urban affairs, smoking, and auto safetyâover a much longer period of time to reveal patterns of stability alternating with bursts of rapid, unpredictable change. A welcome corrective to conventional political wisdom, Agendas and Instability revises our understanding of the dynamics of agenda-setting and clarifies a subject at the very center of the study of American politics.
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