Can Health Insurance Regulations Generate Citizen Constituencies?

Abstract

Abstract Context: A political science literature has emerged on the policy feedback effects of alternative health care coverage expansions, focusing on whether programs like Medicare, Medicaid, and the Affordable Care Act can generate robust public constituencies. Yet, scholars have mainly examined direct governmental benefits and rarely studied the feedback effects from the underlying regulatory frameworks that allow health care markets to function, such as regulations that determine eligibility for nongroup and continuation coverage. Methods: Drawing on literature from multiple disciplines, this article analyzes political and policy factors that promote and undermine such regulations' capacity to stimulate positive feedback and the emergence of citizen constituencies. Findings: While some factors may help these regulations to cultivate constituencies, there are barriers to this positive feedback generation. The most notable is the failure of these regulatory policies to confer politically useful resources on citizens unless other, mutually supportive policies are also in place, such as policies to control premiums. Conclusions: Steps in the policy feedback model that are typically left unexplored in the literature deserve greater scrutiny when scholars examine the weak self-reinforcing effects of health insurance regulations. A take-away lesson, relevant to the Affordable Care Act, is that even when policies broaden nongroup coverage and ostensibly assist many people, a robust citizen constituency is unlikely to emerge, leaving key protections of access to health insurance vulnerable to erosion or reversal over time.