Determinants of Attitudes toward the Affordable Care Act in Kentucky, Ohio, and Tennessee

While many scholars have explored the individual determinants of attitudes toward the ACA and healthcare reform more generally, few have concentrated on the policy environment at the state level. This is a significant oversight given that many of the policy specifics of the ACA, such as the creation of insurance exchanges and the expansion of Medicaid, are decided at the subnational level. I take a first step in understanding how the policy design of the ACA influences opinions by looking at Kentucky, Ohio, and Tennessee because they differ in significant ways regarding their policy decisions toward the ACA. Using a policy feedback theory approach, I find significant differences in opinions towards the ACA across the states with citizens in Kentucky being more favorable towards the ACA compared to citizens in Ohio and Tennessee. Additionally, Republicans in Kentucky are more favorable towards the ACA compared to Republicans in Ohio and Tennessee. As such, the effect that subnational policy design has on political behavior and attitudes is key to understanding how individuals react to health reform.