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RSF: The Russell Sage Foundation Journal of the Social Sciences

"The Social, Political, and Economic Effects of the Affordable Care Act"

Edited by

Andrea Louise Campbell
Department of Political Science
Massachusetts Institute of Technology

and

Lara Shore-Sheppard
Department of Economics
Williams College

The Patient Protection and Affordable Care Act, commonly referred to as the ACA, was the most significant reform of the American health care system since the passage of Medicare and Medicaid a half century ago. The “affordable care” portion of the act sought to expand coverage to the uninsured through Medicaid expansion and the creation of insurance marketplaces with sliding-scale premium subsidies, cost-sharing subsidies, and rate restrictions, as well as the requirement that dependents be permitted to remain on parental insurance plans up to age 26. The “patient protection” portion included new regulations aimed at increasing access and improving insurance coverage, such as guaranteed issue, a prohibition on pre-existing condition exclusions, no annual or lifetime caps on expenditures for covered services, coverage of essential health benefits, and free preventive care, among others. This portion also included provisions implementing pilot and demonstration projects aimed at exploring new payment and care models such as Accountable Care Organizations (ACOs) or bundled payments, and new care coordination models for dual Medicare-Medicaid eligibles and other populations.  Finally, there were a number of additional provisions, such as increased funding for community health centers and incentives for states to continue rebalancing their Medicaid long-term care spending toward home- and community-based services.

Although nominally focused on changing various components of the health care system, the ACA touched on a broad variety of social institutions and societal relationships. Connections between states and the federal government, between governments and health care providers, between governments and individuals, and between individuals and firms all were altered by the ACA.  Taken together, the elements of the ACA had the potential to spur major societal changes beyond extension of health insurance coverage.  Indeed, the law’s passage was followed by continuous challenges in Congress, in the courts, and in the states, due in part to the far-reaching nature of the law’s provisions.  In addition to spurring considerable political discourse and action, these challenges affected the ACA’s implementation and may have changed its impacts.  Six years after the law’s passage, elections ushering in unified Republican control of government at the national level and Republican control of government in many states potentially altered the environment surrounding the law and its implementation as well.

While there has been considerable high-quality social scientific research done on the effects of the ACA, much of this work has focused on a very limited set of ACA provisions, with less focus on the broader impacts of the law and the challenges to it.  It is important for social scientists to investigate, and to provide evidence about, the impact of the law on societal institutions and on fundamental societal relationships.  With fewer than nine years since the law’s passage and fewer than five since full implementation was intended to occur, many effects of the law may have yet to be seen, but even relatively short-run changes may be substantial.  This call aims to encourage proposals for papers examining the social, political, and economic effects of this major health system reform in its first decade.

In what follows, we lay out a set of possible topics and research questions. We are particularly interested in papers that focus on the broad impacts of the law and its implementation, including the challenges to its implementation, on major social, political, and economic relationships.  We encourage research that goes beyond the ACA provisions commonly examined thus far (such as the creation of insurance exchanges and the Medicaid expansion) and the types of analyses commonly carried out (such as Medicaid expansion state difference-in-differences models). As we lay out below, we are interested in papers that examine institutional effects as well as those that examine effects on individuals. Given the uncertainty that has surrounded the ACA and its implementation, we are interested in research that explores the extent to which uncertainty has shaped the ACA’s effects.

We invite proposals from scholars across all of the social sciences, including but not limited to economics, political science, psychology, public health, public policy, social work, and sociology.  We welcome proposals for papers using various methodological approaches (quantitative, qualitative, or mixed-methods) and are particularly interested in papers that use strong disciplinary tools but push beyond disciplinary boundaries in their focus. Our main criteria for selection will be the connection between clear theory and empirical approach, the rigor of the empirical analysis (regardless of method), the interpretation of findings, and the quality of writing.

The editors welcome abstracts related to topics such as (but not restricted to):

Institutional effects
In its design and implementation, the ACA incorporated a substantial role for the federal government. In addition, Republican control first of Congress and then of the presidency altered the political environment surrounding ACA implementation and ushered in a series of administrative changes at the federal level that reshape many of the law’s provisions. We are interested in questions examining the effects of the original design features at the federal level, as well as subsequent changes to those features.

  • How have challenges to the validity of the law during its implementation affected the policies put in place as a result and the outcomes of those policies?
  • What are the effects on enrollment and other outcomes of reduced federal funding for advertising and for navigators or the reduced enrollment period?
  • What are the effects of changes not only in the more visible elements of the law, such as the elimination of the individual mandate penalty, but also in the less visible components, such as the Medicare or non-insurance provisions?
  • What are the bureaucratic and managerial challenges associated with Accountable Care Organizations (ACOs) and other demonstration projects, and how has the policy environment affected what can be learned from such demonstrations?

 

States play a key role in many components of the ACA. How do the course of implementation and policy outcomes vary with the political economy and policy environment in different states?

  • How have state lawmakers and bureaucracies responded to federal decisions and regulations? How have they developed the parameters of their states’ involvement (state marketplaces, state Medicaid programs, state individual mandates, state marketing expenditures)?
  • How effective are state insurance regulators or navigators in different political environments or in states that are more or less accepting of the law?
  • To what extent do elements of the ACA affect the functioning of other public programs, particularly nutrition and food programs, housing assistance, or income assistance? How does ACA implementation interact with political conflicts over other policies, including those involving poverty and social welfare, tax relief, and government subsidies, e.g. to farmers?
  • How have state lawmakers and bureaucracies responded to potentially conflicting interests expressed by firms and by residents in the state (i.e., not just “top-down” pressures from federal government decisions but also “bottom-up” pressures)?

 

While the focus of many ACA provisions was the individual, other provisions had the potential to affect both for-profit and not-for-profit firms and organizations.  Large employers were required to offer coverage, insurers faced new regulations, hospitals and health care systems faced new regulations and were offered new opportunities, and community health centers and community service agencies potentially gained greater funding and support.

  • To what extent has the implementation of the ACA affected non-governmental providers of social services?
  • To what extent have affected industries and firms responded to the ACA?What has been the impact on firms who sponsor insurance for their workers?
  • To what extent have firms and non-profits altered their business models, patterns of lobbying, and enterprise investment decisions in light of the ACA and the uncertainty surrounding its future? For example, to what extent have ACA provisions affected merger activity or network formation among insurers or providers, or provider decisions about accepting some ACA health plans? Have firm concentration, firm survival or profitability changed because of the ACA?To what extent has access to care or cost of care been affected by these business decisions?
  • Changes to Medicare both large and small were intrinsic parts of the ACA.To what extent have such changes, including those aimed at exploring new payment and care models such as Accountable Care Organizations (ACOs), affected health care providers?

 

Effects on individuals
The ACA confers significant resources on low- and moderate-income households and others excluded from the employer-based insurance system. At the same time, many stakeholders and constituencies argue that their well-being has been made worse by the ACA:  for example, small business owners; farmers; entrepreneurs; physicians; senior citizens; people who have incomes just above the income limit for subsidies; or people with employer-sponsored insurance with high copayments or deductibles who may feel their insurance is more expensive than Medicaid.

  • For intended beneficiaries of the ACA, what are the effects on financial hardship, on labor market decisions such as changing jobs, entrepreneurship, or retirement, or on investment decisions such as investment in human capital? What are the effects on family relations or happiness? How have individuals who were not the intended beneficiaries of the ACA been affected by the law?
  • How has the ACA affected measures of inequality, including of income, earnings, or wealth? What have been the distributional consequences of provisions of the ACA?
  • What are the effects of the ACA on employment, safety net participation, and other outcomes among those traditionally excluded from employer-provided insurance and/or underserved by the existing private and public social welfare systems:immigrants and families with mixed immigration status; youth; the unemployed, early retirees; the disabled; prisoners; the homeless?
  • Has the ACA increased access to behavioral health care, and if so, how has it done so? How has the coincidental timing of the implementation of the ACA and the increase in opioid overdoses and addiction affected demand for care and policy responses?
  • Has the ACA changed views of Medicaid or of health insurance for groups whose access to insurance is facilitated by the ACA?
  • To what extent are constituencies being mobilized to defend the ACA in the face of challenges to it, and by whom? To what extent are new advocacy groups forming or existing groups redeploying resources or adopting new strategies to combat challenges to the law?
  • Has the ACA changed patterns of political participation among beneficiaries or non-beneficiaries?

 

Anticipated Timeline

Prospective contributors should submit a CV and an abstract (up to two pages in length, single or double spaced) of their study along with up to two pages of supporting material (e.g. tables, figures, pictures, etc.) no later than 5 PM EST on 12/7/18 to:

https://rsf.fluxx.io

All submissions must be original work that has not been previously published in part or in full. Only abstracts submitted to https://rsf.fluxx.io will be considered. Each paper will receive a $1,000 honorarium when the issue is published. The journal issue is being edited by Andrea Louise Campbell, Department of Political Science, MIT and Lara Shore-Sheppard, Department of Economics, Williams College. All questions regarding this issue should be directed to Suzanne Nichols, director of publications, at journal@rsage.org and not to the email addresses of the editors of the issue.

A conference will take place at Russell Sage in New York City on 5/29/19 with a group dinner taking place the night before. The selected contributors will gather for a one-day workshop to present draft papers (due on 4/30/19, a month prior to the conference) and receive feedback from the other contributors and editors. Travel costs, food, and lodging will be covered by the foundation. Papers will be circulated before the conference. After the conference, the authors will submit their final drafts on or before 7/31/19. The papers will then be sent out to three additional scholars for peer review. Having received feedback from reviewers and the RSF board, authors will revise their papers before 12/17/19. The full and final issue will be published in the fall of 2020. Papers will be published open access on the RSF website as well as in several digital repositories, including JSTOR and UPCC/Muse.

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