Could the Patient Protection and Affordable Care Act Have a Legitimacy Problem?

Public skepticism about the Patient Protection and Affordable Care Act could in a sense turn out to be self-fulfilling.  The success of the Exchanges will depend in large part on how many people enroll in them, that is, how many people comply with the individual mandate and sign up for insurance rather than take the tax penalty.  That is why we are starting to talk more and more about how many people will wind up enrolling; it’s important.  (For further reading in that vein, see Seth Chandler’s interesting post at his blog doubting that enrollment will reach projections, and John McDonough’s cautious predictions based on experience with the Massachusetts health insurance mandate.)

Many have based their projections on the Massachusetts experience, which is an interesting comparison for several reasons, for me none more than this one: the Massachusetts mandate was relatively uncontroversial.  One survey showed 64% approval for the law in general and 52% approval for the mandate.

It goes without saying, but the PPACA has not enjoyed that kind of popular support, for a variety of reasons.  According to a recent poll, the law enjoys only 40% approval in general and only 34% approval for the individual mandate.

In theory the law is the law, so the fact that the Massachusetts mandate was more popular than is the PPACA’s individual mandate should not affect compliance.  Rather, that should be determined by the difference between the monetary penalty for non-compliance and the cost of a complying health plan.  (Under the PPACA in year one, the penalty is $95 or 1% of your taxable income, whichever is higher; under the Massachusetts law in year one, it was $219.  So the PPACA’s penalty is higher for those making more than $21,900 in taxable income.  I haven’t compared the premiums of complying plans in Massachusetts year one to the premiums of plans on the Exchanges.)

But there is research that suggests that the controversy surrounding the law could matter for compliance.  Specifically, a number of studies conclude that our perceptions about a law’s legitimacy have a big influence on our decision whether to comply with the law.  A great starting point for those interested in this line of research is Tom Tyler’s book, Why People Obey the Law.  Also, co-blogger Michelle Mello has a recent article in Health Affairs about public support for various public health interventions.

In my view, this perspective makes the Massachusetts comparison even more interesting.  If perceived legitimacy is indeed a significant factor in whether people comply with a law, then we should expect compliance with the individual mandate to fall well short of the Massachusetts experience.  Indeed, it would be hard to find a law that has had its legitimacy called into question more than the PPACA.

If, on the other hand, people comply with the PPACA at the same rate than they complied with the Massachusetts mandate, it would create some reason for doubt about the explanatory power of the legitimacy theory of law-abiding behavior.  (Of course there are many additional complicating factors.)

Stay tuned!  As Buck Showalter would say, we need only wait: Our curiosity will be satisfied.

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