How Ideology, Party, and Public Opinion Shape How Legislators Craft Health Care Policy

December 11, 2018

The ongoing fight over health care in the U.S. played a role in the midterm elections in many states. According to Marketwatch, over 41% of voters in exit polls said that health care was the top issue facing the country. And though President Trump and GOP leaders have previously vowed to “repeal and replace” the Affordable Care Act, voters in several states approved new ballot initiatives to expand Medicaid under the ACA. 

As part of RSF’s special initiative on the Social, Economic, and Political Effects of the Affordable Care Act, grantee Boris Shor (University of Houston) is studying the extent to which state legislators represent their constituents’ preferences on health care. Using newly available data on ideology, roll-call votes, and interest groups from different states, he is comparing legislators' responsiveness to constituents across districts. He is also studying how factors such as partisanship, ideology, special interests, and constituency opinions and needs affect legislators' behavior. 

In a new article for State Politics and Policy Quarterly, Shor discusses how these factors and more influences how individual legislators voted on the Affordable Care Act by state. His abstract reads:

Why do state legislators vote the way they do? Which influence is predominant: ideology, party, or public opinion? The implementation votes surrounding the Affordable Care Act (ACA) provides a unique setting to examine this question, as they make all three considerations highly salient. State roll call votes on ACA implementation were sometimes polarized and sometimes unexpectedly bipartisan. What accounts for the heterogeneity in individual legislator behavior on bills implementing the ACA at the state level? Using new data on legislator ideology and votes from 2011–2015, I show evidence that legislator ideology was by far the most important predictor of voting on implementation votes, far more so than legislator party or public opinion. Moreover, I show the influence of ideology is heterogeneous by issue area and bill.

Read the paper in full.

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