Death by a Thousand Cuts

The Trump administration’s 2017 decision to slash the advertising budget for the Affordable Care Act’s health insurance Marketplaces by 90% outraged many in the public health, policy, and medical communities. Yet, little evidence exists correlating the running of televised advertisements encouraging consumers to visit the Marketplace and purchase health insurance. A recent study published in Health Affairs combined data from 37,982 respondents participating in the  National Health Interview Survey with data on volumes of televised advertisements aired in the respondent’s county of residence. 

The authors looked at six types of advertising content: private, federal, state, and other sponsors, political advertising, and news mentions. They demonstrated that people exposed to federally sponsored advertising were about 7% more likely to enroll in a Marketplace plan, but if exposed to negative political ads disparaging the ACA, they were about 21% less likely to enroll in a Marketplace plan. This is remarkable, considering that the authors controlled for annual income and insurance status in 2013, the variables most strongly associated with insurance uptake overall.

The effectiveness of negative political ads in dissuading Americans from enrolling in a Marketplace plan is discouraging to say the least—these results are similar to the Truth campaign’s effectiveness in reducing cigarette smoking in teens, considered one of the most successful social marketing campaigns of the past two decades. However, the effect of federally sponsored ads on insurance uptake was very small, and slashing this part of the ACA’s budget did save taxpayers $90 million dollars. 

In my own experience connecting poor and marginalized people to health insurance in West Baltimore, television advertising has very little to do with it. In the grand scheme of the Trump administration’s assault against public health, slashing the advertising budget for the ACA is the least of our problems.

Abstract

The effectiveness of health insurance advertising has gained renewed attention following the Trump administration’s decision to reduce the marketing budget for the federal Marketplace. Yet there is limited evidence on the relationship between advertising and enrollment behavior. This study combined survey data from the 2014 National Health Interview Survey on adults ages 18-64 with data on volumes of televised advertisements aired in respondents’ counties of residence during the 2013-14 open enrollment period. We found that people living in counties with higher numbers of ads sponsored by the federal government were significantly more likely to shop for and enroll in a Marketplace plan. In contrast, people living in counties with higher numbers of ads from political sponsors opposing the Affordable Care Act (ACA) were less likely to shop or enroll. These findings add to the evidence base around advertising in the ACA context.

PMID: 29863916 

Gollust, SE, et al. Health Aff. 2018; 37 (6): 956-963.