The Affordable Care Act is a landmark piece of social legislation with the potential to reshape health care in the United States. Its potential to reshape politics is also considerable, but existing scholarship suggests conflicting expectations about the law's policy feedbacks, especially given uneven state-level implementation. In this article I focus on the policy feedbacks of the law's Medicaid expansion on political participation, using district-level elections data for 2012 and 2014 US House races and cross-sectional survey data from 2014. I find that the increases in Medicaid enrollment associated with the expansion are related to considerably higher voter turnout and that this effect was likely due to both an increase in turnout for new beneficiaries and a backlash effect among conservative voters opposed to the law and its implementation. These results have important implications for our understanding of the ACA and of the impact of welfare state expansions on political participation, particularly in federalized systems.

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Context: Recent studies have shown that changes in public health insurance policy have the potential to affect political participation. In particular, aggregate-level analyses suggest that increases in Medicaid enrollment due to the Affordable Care Act's Medicaid expansion are associated with increased voter turnout. Given the current uncertainty surrounding the future of Medicaid, these results lead to an important and related question: What happens to political participation when public health insurance coverage is reduced? Methods: Leveraging changes instituted by the state of Tennessee in the early 2000s to its Medicaid program, TennCare, the authors employed a first-differences approach to examine the effect of health policy retrenchment on county-level voter turnout and partisan vote share in gubernatorial elections. Findings: Counties with larger Medicaid enrollment declines saw larger decreases and smaller increases in voter turnout between 2002 and 2006 relative to those with smaller declines. Disenrollment was also associated with reduced Democratic vote share, though these results are not robust to controls. Conclusions: Rather than mobilizing voters angry about losing coverage, the TennCare disenrollment seems to have had a demobilizing effect. The negative resource and interpretive effects of losing coverage likely outweigh any mobilizing backlash effect of retrenchment.

The method in which a government policy is delivered-for example, as a tax break rather than a direct paymentcould potentially have significant implications for how the public views that policy. This is an especially important consideration given the importance of indirect policy approaches like tax breaks to modern American governance. We employ a series of survey experiments to test whether citizens react more favorably to tax breaks than to equivalent spending programs. We find that citizens prefer tax breaks, particularly when they are the established means of intervention. When direct intervention is the status quo, or when any government involvement on the issue is unfamiliar, the preference is reduced. We also find an interactive effect for ideology, with conservatives strongly preferring tax breaks to direct intervention, though the effect is still present among liberals. This study establishes the importance of delivery mechanism to citizens' policy preferences and suggests that the policy status quo structures citizens' perceptions of policy proposals.