The Supreme Court today upheld the Affordable Care Act of 2010, otherwise known as Obamacare. Judging from the polls, American public opinion appears to be very sharply divided over the legislation. Some view it as socialism, others as the first success in a half-century of efforts to achieve a sensible national policy on health care.
What explains the wide divergence of views? An economists’ approach – cynical or naïve depending on how you look at it – would be to assume that citizens vote according to their own personal interests. Getting the uninsured onto paid insurance through the individual mandate is very much in some people’s interest, but not necessarily as strongly in others’ interests. Let’s take a look.
Those who have the most to gain from President Obama’s health care legislation are those who have a pre-existing condition or are pre-disposed to illness, for example because they are overweight. They are more likely to need medical care in the future, but can be charged higher rates if they try to buy private insurance, by virtue of their condition. Or they can be excluded completely. (Each obese American incurs medical costs 42% higher than those of normal weight.)
Figure 1: States with higher obesity rates tend to oppose the Affordable Care Act 
I show how Congressmen from each state voted on the Affordable Care Act on the vertical axis of Figure 1, with the state rates of obesity on the horizontal axis. There is a statistically significant relationship. But the relationship goes the other way: states where more people are overweight, such as Mississippi, Alabama, South Carolina and Texas, are more likely to oppose Obamacare. In those parts of the country where people are slimmer, such as New England, New York and Colorado, there is strong support for health care reform. For every one percentage point increase in obesity, support for Obamacare declines by an estimated four percentage points on average.
Obesity is partly genetic, of course, but also is determined by habits of exercise and eating. The states where residents get the most physical exercise are Minnesota, Utah, Oregon, Washington and Vermont; the states that get the least are Mississippi, Tennessee, Kentucky, Lousiana and Alabama. Another data source tells us the states with bad eating habits: the five worst-ranking are Mississippi, Alabama, Missouri, Kansas and Oklahoma.
There are some outliers, of course. Utah’s population appears to be physically fit (and to do well by other measures that we will be looking at later), while opposing the Affordable Care Act and voting Republican. Mormons look exceptional in the extent to which they abide in their personal lives by the strictures of their religion. Could this be why evangelicals tend to resent Mormons so much according to opinion polls?
It’s not just obesity and exercise. The states that rank the best on an overall health index are Vermont, New Hampshire, Massachusetts, Minnesota, and Maine and Iowa. The states where people are the least healthy overall are Louisiana, Mississippi, New Mexico, Nevada, Oklahoma and Texas. The weight of the evidence is fairly clear: the states where people are most in need of help getting private insurance are the states opposing the legislation that helps them do that. (I hope in future blogs to look at such other specific risk factors as unprotected sex, drunk driving, and smoking habits.)
It seems that the economists’ view of the world is wrong. People are not voting in their self interest. What is going on here?
I can think of two plausible explanations as to why those who stand to benefit from Obamacare should oppose it politically: (1) lack of knowledge regarding the bill, and (2) partisanship.
Most people don’t know what Obama’s bill does. Many think that it reduces personal responsibility for health care. But the truth is the opposite. Under the current system, hospitals are required to treat patients who show up at the emergency entrance with a heart attack – even if their condition is partly their fault, due to habits of overeating and under-exercising. The hospitals have to pass the costs on, and the rest of us end up footing the bill. The individual mandate is designed to fix that, by making everyone pay for the health care they get (and perhaps even encouraging them to see a doctor who will advise them to adopt a healthy life style). Establishing personal responsibility, not socialized medicine, is the reason why conservative think tanks such as the Heritage Foundation proposed the idea of the ndividual mandate in the first place, and why Mitt Romney enacted it in Massachusettts. But most people still seem unaware of this. If people do not understand their economic interests, that may explain why the voting patterns do not line up correspondingly.
The other, not inconsistent, explanation, is that people are voting along simple party lines. Figure 2 shows the popular vote in the 2008 presidential election on the vertical axis, state by state. The states where people are most likely to be overweight or obese tend to vote Republican. Evidently the people in New England, New York, Hawaii and DC, who tend to vote Democratic, are slimmer. A one percentage point increase in the obesity rate is estimated to raise the ratio of Republican to Democratic voters from 1.00 to 1.06 (easily enough to swing an election). The statistical confidence interval — “margin of error” — is thin enough to exclude the possibility of a zero effect.
Figure 2: States with higher obesity rates tend to vote Republican 
Ideology is much less important than party affiliation. This is the same result when one looks at which states receive more federal subsidies: despite all the rhetoric about “getting the government off our backs,” it is the red states, i.e., those where people vote Republican, that receive the most transfers from Washington. Alaska, Mississippi, Louisiana, West Virginia, and the Dakotas top the list. The Democratic-leaning states are the ones paying into the federal government and subsidizing everyone else: New England, New York, New Jersey, California. Those who claim to be fiscally conservative are the ones who in fact tend to feed voraciously at the public trough.
[Econometric results are available in an appendix.]