Nolan Kavanagh
Dissertation Title: "Three Essays on Health Policy and Politics"
This thesis uses a combination of causal and descriptive designs, paired with economic and political science theory, to explore the feedback loop between health policies, health, and politics.
Paper 1 - The Effect of Expanding Public Health Insurance on Partisan Identification (with JR Jolin, AL Campbell)
Can transformational public policies change partisan identification? We argue that they can, if they are politically salient, associated with one party, and provide meaningful benefits or associate the responsible party with particular social identities. To test this theory, we revisit the Affordable Care Act (ACA), a politically salient expansion of health insurance to millions of Americans, using the natural experiment of Medicaid expansion. Using a difference-in-differences with event study design over 17 years, we show that Medicaid expansion produced an enduring 2.7 percentage-point increase in the proportion of adults who identify as Democrats. This amounts to 4 million Democrats in treated states. The effects were concentrated among low- and middle-income adults and non-white adults. They were also limited to states where Democrats were responsible for Medicaid expansion, consistent with the three mechanistic criteria. Our findings suggest that politically salient policies can prompt Americans to reconsider even fundamental aspects of their political identities.
Paper 2 - Health and the Health System as Drivers of Democratic Discontent (with C Ojeda, K Croke, ME Kruk)
Democratic backsliding has prompted a search into the drivers of democratic discontent. Existing work has emphasized the importance of public institutions and their responsiveness to the public's needs, but what is the role of health and the health system? To explore it, we draw on four high-quality, international surveys, including a novel large-N survey yet to be used in the political science literature. Together, our analyses include 1,046,653 respondent-years in 109 countries and subnational regions, representing 88% of the world's population. Using a variety of descriptive tools, including selection on observables, individual fixed effects models, and structural equation modeling, we demonstrate that poor health is systematically linked to anti-democratic attitudes and values. The between-individual associations hold in both more and less democratic regimes, and in panel data, they hold within individuals. Structural equation modeling suggests that attitudes about the health system and other public institutions are essential mediators between health and democratic orientation. Taken together, these findings suggest that people who have negative experiences with health and the health system are especially disinclined to support the democratic process and democratic values.
Paper 3 - Beneficiary and Insurer Responses to a Surge of Active Choice: Evidence from the Medicare Advantage Market (with T Layton, B Vabson, ME Chernew, JM McWilliams)
In markets that involve complex decision-making, inertia can disincentivize consumers from re-evaluating their choices over time and disincentivize firms from competing for these inertial consumers. Can pushing consumers to make an active choice induce firms to offer more competitive products that benefit consumers? We take advantage of an exogenous shock to the Medicare Advantage markets in Minnesota in 2019 that induced 40% of consumers to select new health insurance plans. Using a difference-in-differences with event study design, we find that this push toward active choice led to the entrance of several insurers into treated counties, where insurers offered more plans with wider networks and more supplemental benefits at similar or lower total costs to beneficiaries. Within treated markets, consumers induced to make an active choice ended up selecting higher-value plans than those who were not. These findings suggest that policies to discourage inertia can lead to welfare gains for consumers, in part by encouraging firms to compete more actively for existing consumers.