Republicans less likely to accept ACA subsidies to purchase health insurance

Republicans who buy individual health plans may be less likely to shop through marketplaces created under the federal Affordable Care Act, leading to them to forgo subsidies provided by the federal government, according to a new study.

Examining the behavior of enrollees of a large health plan in New England, researchers found that Republicans who bought individual plans were less likely than Democrats to make use of subsidies that they were eligible to receive—forgoing an average of about $800 annually as compared to similar Democrats.

Neither Republican nor Democratic subscribers fully took advantage of all the subsidies that were available to them. But researchers found that the overall financial impact of not making use of subsidies was roughly double for Republicans as compared to Democrats.

The study is published in the September edition of the journal Health Affairs.

"These findings suggest that political polarization may lead some individuals to not make full use of federal programs intended to make health care coverage more affordable for Americans," said Joachim O. Hero, the study's lead author and an associate policy researcher at the RAND Corporation, a nonprofit, nonpartisan research organization.

"With the size of federal health care subsidies growing, it will be a challenge for policymakers to develop marketing and education programs that avoid labels and language that bring to mind contentious political battles at the national level," Hero said.

Researchers say that one approach to improve uptake of health care subsidies may be to make the assistance available to eligible consumers who use alternatives to the publicly run health insurance exchanges operated under provisions of the Affordable Care Act.

The analysis was conducted within a larger study examining consumers' preferences and behaviors in the nongroup insurance market.

Two surveys, a baseline in 2017 and a follow-up in 2018, were sent to a random sample of nongroup plan subscribers aged 18 to 63 from a single health insurer serving New Hampshire, Maine and Massachusetts. During the study period, potential subscribers in New Hampshire and Maine used the federal marketplace platform (HealthCare.gov) to enroll in Marketplace plans, while potential subscribers in Massachusetts used a state marketplace platform.

A total of 1,223 people completed both surveys, which asked participants about sociodemographic and clinical information, education, income, family composition and a number of questions about party affiliation and political views.

Information from the survey was merged with health insurance enrollment records, including source of enrollment (on versus off government marketplace), federal subsidies applied to plan premiums and health plan characteristics.

The study found Republican subscribers in nongroup health plans generally were less likely to enroll through the ACA Marketplaces than Democratic subscribers with the same sociodemographic profile.

However, there was no difference in ACA Marketplace participation or subsidy take-up by party among people in the lowest income groups (those with less than 250% of the federal poverty level), who were eligible for subsidies worth thousands of dollars.

Similarly, no party differences were observed among those who had chronic illnesses, who typically have higher overall health care spending.

Examination of write-in responses on the surveys found expressions of both support and opposition to the Affordable Care Act as the reasons for or against enrolling through the government-run Marketplaces.

"Coordination with individual carriers and brokerage networks or greater ability to enroll through private websites, may expand opportunities for eligible subscribers to enroll in subsidized plans via avenues that feel more comfortable or less politicized," Hero said.

Support for the project was provided by the federal Agency for Healthcare Research and Quality. Other authors of the study are Anna D. Sinaiko of the Harvard T. H. Chan School of Public Health, Alon Peltz and Alison A. Galbraith, both of the Harvard Medical School and the Harvard Pilgrim Health Care Institute, and Jon Kingsdale of the Boston University School of Public Health.