Leadership matters

I’ve been asked several times and in several ways how and why health reform will play out differently across the states. In part, this has already been addressed by me and Aaron Carroll on this blog (see also my latest Kaiser Health News column with Kevin Outterson).

One thing I’ve not yet highlighted (or not fully) is the role of leadership. It’s plausible that the way state-level public figures talk about health reform will affect how populations in different states respond, particularly to the mandate. Is there any research that suggests a link between leadership and response to public programs? Yes, there is! I did some, with Steve Pizer and wrote a summary on this blog. The work was about the the relationship between enrollment in Medicare prescription drug plans (PDPs) and the popularity of the administration promoting the program (President Bush).

We hypothesized that beneficiaries might have substituted the recommendations of respected political leaders for the less accessible calculations of expected financial values of Medicare [drug] plans.

To put it bluntly, perhaps some beneficiaries heard Bush and others in his Administration touting the benefits of the new drug plans. Finding it otherwise difficult to make their own independent assessment of the relative merits of various coverage options, beneficiaries may have substituted officials’ enthusiasm for PDPs for their own prediction of its benefits. That’s a type of shortcut many of us make: we rely on the “expert” advice of others we trust rather than do our own analysis. In this case, there is geographic variation of degree of trust in the Bush Administration, which we operationalized as proportion of 2004 Bush vote. […]

We found that the effect of the Bush vote is larger than the effect of other variables that are generally accepted to be important and relevant factors associated with enrollment decisions: premium, level of beneficiary educational attainment, county urban/rural status, provider density, income, and diagnosis based risk score.

So, an administration’s enthusiasm and popularity can have a significant impact on the early response to a new program [even controlling for all other generally accepted factors of relevance].

It’s pretty easy to apply this to health reform. If state leaders continue to describe that reform, or the mandate, in negative terms, I would expect much less enthusiasm for participation. On the other hand, if leaders talk about reform more positively, the population may more readily accept it, including the mandate.  Since we’ll likely see, as we have, state variation in how local leadership talks about reform, that will play a role in the variation of acceptance of it and compliance with the mandate.

It is worth noting a source of endogeneity. It is likely that factors that affect acceptance of reform or a mandate also affect preferences for type of leadership. In other words, a population that is predisposed to reject a mandate may select leaders who are more likely to do so as well. Does leadership cause acceptance of public programs or do public attitudes that relate to rejection of those programs affect leadership? My analysis can’t say. It’s likely some of both.

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