Abstract
This paper undertakes a peer review of a research article that employs a partisan lens to respond to some of the most prominent issues that cropped up after the Affordable Care Act (ACA) was passed into law. The research article focuses on the political controversies that continue to surround health insurance exchanges from a Republican perspective. Although the article provides useful insights on how political considerations continue to affect and influence healthcare policies in the American context, it has several weaknesses that dilute its credibility and readability. Some of the weaknesses identified in this peer review include the inability of the researchers to limit the scope of the study, methodological challenges, poor presentation of results through excessive reliance on narratives, and inadequate synthesis of findings.
Main Points
The article uses a partisan perspective to respond to issues that arose after the Affordable Care Act (ACA) was passed into law. The main issues that have been identified by the authors include how the Republican state leaders responded to the insurance exchange dilemma triggered by the ACA, why many states perceived to be Republican hotbeds refused to support the establishment of health insurance exchanges, and the factors that came into play to force Republicans to shift alliance on the exchange issue (Jones, Bradley, & Oberlander, 2014). These issues are important as they serve to demonstrate how politics and orientations affect health policies in America and, by extension, the provision of healthcare in the country. However, although the issues are interrelated, it would have been plausible to redefine their scope with the view to focusing the topic on a single issue. Research is consistent that studies that limit their scope to a single issue or problem are able to provide more valid and reliable findings (Amerson & Strang, 2015).
The authors did an excellent job in examining the historical trends, growth, and political maneuvers that have characterized the health insurance exchanges debate in contemporary contexts. The authors also consulted relevant academic sources and other documents in exploring how several Republican-led states responded to the exchange provision embedded in the Act and the reasons that informed the shifts of allegiance. Additionally, the authors were thorough in their exploration of political issues that informed the decision by Republican-led states to opt-out of the comprehensive federal-run health insurance exchange and embrace devolved state-run insurance exchange programs. These issues have been explored in other studies (e.g., Nadash & Day, 2014; Vesely, 2011 ), with the major finding being that raw political standpoints pitying Democrats against Republicans are to blame for the poor reception of the Act in general and the refusal by some states to implement the exchanges in particular. For example, some scholars have argued that the refusal by some states to implement the health insurance exchanges as enshrined in the ACA arises more from perceived fears of embracing policies initiated by Democrats than from credible concerns for an Act that was poorly designed (Jones & Greer, 2013).
Approach/Methods
The authors addressed the issues by drawing on interviews conducted for two years “with more than ninety officials in the legislative and executive branches of twenty-four states, including advisors to governors, state legislators and their staffs, consultants, and bureaucrats at state departments of insurance and health” (Jones et al., 2014, p. 100). The views of congressional staffers and interest groups were also collected using the interview data collection technique, while quantitative information was sourced from state legislative roll call data as well as primary and secondary materials. Although these sources are adequate in collecting relevant data on the issues raised, the authors failed to discuss the study design to enable readers to develop an adequate understanding of how the study was planned. The minimal explanation of the study methods makes it hard for readers to understand the variables that were of interest to the study and how they were operationalized to provide answers to the main issues. Available literature demonstrates that sufficient operationalization of the study variables allows researchers to undertake a truthful evaluation of the cause and effect relationships or associations between independent and dependent variables (Creswell, 2013).
Although the researchers used the interview technique to collect some of the data from the field, it is not clear how the participants were sampled and the inclusion criteria used to qualify them for participation. Owing to the fact that political orientations are largely subjective, it could have been prudent for the researchers to discuss their sampling strategy and inclusion criteria to allow readers to make an informed decision on whether the findings could be generalized to the whole population (Creswell, 2013). This is particularly important considering the fact that the main issues of interest in the study are often interpreted differently by Democrats and Republicans. Lastly, the authors did not take the time to explain the primary and secondary sources that formed the basis for data collection. Again, it would have been appropriate for the authors to have a section on how these sources were identified and the techniques used to analyze them. Overall, these weaknesses make it difficult for readers to generalize the study findings to the whole population.
Interpreting the Research
The authors made several important discoveries on the issues that had been raised to serve as the purpose of the study. First, they provided data to show that the controversy surrounding the creation of state-run, regulated insurance marketplaces for uninsured individuals and small businesses was ignited by partisan polarization and perceived fear of a federal “takeover” of the US health care system by Democrats. The authors backed this assertion with findings of other research studies, implying that their own analysis is correct. In the issue of evolving Republic reactions, the authors made use of secondary sources of data to demonstrate that the genesis of the reactions is embedded in political considerations that questioned the constitutionality of the ACA and the propensity to gain political appeal among the masses (Jones et al., 2014).
It is also clear that most Republican-led states were opposing the exchange provision due to reasons such as fear of destroying the private insurance market, the propensity to settle political scores with the Obama administration, and concerns among some governors emanating from the fact that refusal to support a state exchange could have forced them to cede control to the federal government (Jones et al., 2014). Lastly, the findings demonstrate that some Republican-led states supported the insurance exchanges to be on the safe side in the event that the ACA was declared constitutional by the Supreme Court. These findings are consistent with the results of other studies (e.g., Giaimo, 2013; Jones & Greer, 2013; Nadash & Day, 2014), hence can be passed as credible.
In-state responses to health insurance exchanges, researchers used some descriptive statistics to demonstrate the wider partisan politics in the Implementation of the ACA. Only a small proportion of Republican-led states were in favor of operating state-based exchanges, while a sizeable proportion of Democratic-led states elected to partner with the federal government in rolling out the health insurance exchanges (Jones et al., 2014). Again, these findings have been replicated in other studies (e.g., Jones & Greer, 2013; Nadash & Day, 2014), though it appears that GOP legislators were initially supporting state-led insurance exchanges but changed course to avoid political repercussions associated with supporting the Obama administration. Overall, however, the descriptive statistics used in this section are not easily understandable to the general reader. Additionally, the findings in this section are presented in an opaque manner due to the overreliance on narratives (texts) that blur the reader’s understanding of the real issues. Although the study findings provide important insights on the politics behind the implementation of most healthcare policies, the presentation could have been more eye-catching and interesting to read. Due to these limitations, most readers may find it difficult to complete reading the article and also to develop a coherent understanding of its contents.
Concluding Thoughts
Although the interview data collection technique allows researchers to present the findings in a narrative (text) format, it is the observation of this peer reviewer that the researchers did not undertake a comprehensive analysis and synthesis of the data received from the field to ensure adequate understanding. For example, they could have synthesized the interview data to ensure their findings reflected the issues of interest to the study. Additionally, the researchers failed to limit the scope of the study to ensure a focus on specific issues of interest. The problem of using an expansive scope can be detected in the findings sections, where the researchers used a significant amount of pages to discuss the findings in a somewhat opaque manner. If the scope was limited to one or two issues, it would have been possible for readers to understand the avalanche of data and narratives presented in this article as findings. Finally, it is clear that the article lacks a methodology section and hence it is difficult for readers to generalize the findings.
References
Creswell, J.W. (2013). Research design: Qualitative, quantitative, and mixed methods approach (4th ed.). Thousand Oaks, CA: Sage Publications, Inc.
Giaimo, S. (2013). Behind the scenes of the patient protection and affordable care act: The making of a health care co-op. Journal of Health Politics, Policy and Law, 38(3), 599-610.
Jones, D.K., & Greer, S.L. (2013). State politics and the creation of health insurance exchanges. American Journal of Public Health, 130(8), 8-10.
Jones, D.K., Bradley, K.W.V., & Oberlander, J. (2014). Pascal’s Wager: Health insurance exchanges, Obamacare, and the Republican dilemma. Journal of Health Politics, Policy and Law, 39(1), 97-137.
Nadash, P., & Day, R. (2014). Consumer choice in health insurance exchanges: Can we make it work? Journal of Health Politics, Policy and Law, 39(1), 209-235.
Vesely, R. (2011). Against the clock: As deadlines loom, many states compete against politics, regulations to set up insurance exchanges. Modern Healthcare, 41(28), 6-8.