State‐Level Political Institutions Matter: The Balance of Powers Among Governors, Legislatures, and Direct Democracy Influences Medicaid Expansion Decisions

• Published date: 01 March 2020
• Author: Patrick O'Mahen,Laura Petersen
• Date: 01 March 2020
• DOI: http://doi.org/10.1002/wmh3.329

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doi: 10.1002/wmh3.329

Published 2020. This article is a U.S. Government work and is in the public domain in the USA

State‐Level Political Institutions Matter: The Balance

of Powers Among Governors, Legislatures, and Direct

Democracy Influences Medicaid Expansion Decisions

Patrick O’Mahen and Laura Petersen

Why have some Republican‐controlled states controlled expanded Medicaid while others have not?

Research into state expansion decisions has emphasized partisanship, interest groups, legislative

professionalization, and available resources. In contrast, we evaluate the impact of political in-

stitutions, which are rules that govern how officials reach policy decisions. We explain how different

state institutional structures can lead to different expansion decisions, given similar partisan control

patterns. We describe varying gubernatorial powers over Medicaid programs and analyze the po-

tential of voter‐led initiatives to impose expansion on recalcitrant elected officials. Finally, we describe

how politicians change rules to make it more likely that their preferences are enacted. Overall, focusing

on institutions in addition to partisanship and interest groups more effectively illuminates the ex-

pansion prospects in holdout states. This allows for an effective illustration of potential

roadmaps and roadblocks for pursuing both Medicaid expansion and other state‐level health reforms

that can improve access and equity of health care.

KEY WORDS: Medicaid expansion, Affordable Care Act, U.S. healthcare reform

The Affordable Care Act's (ACA)Medicaid expansion has dramatically in-

creased access to coverage and care among low‐income adults, with few negative

effects (Antonisse, Garfield, Rudowitz, & Artiga, 2019; Mazurenko, Balio, Agarwal,

Carrol, & Menachemi, 2018). Federal matching grants fund 90 percent of the ex-

pansion, which covers all adults in households with income under 138 percent of

the federal poverty line. Despite the benefits, as of fall 2019, 14 states still had not

chosen to expand.

Why not? Research has explored numerous potential answers, but each has a

common feature: partisanship (Barrilleaux & Rainey, 2014; Callaghan &

Jacobs, 2016; Hertel‐Fernandez, Skocpol, & Lynch, 2016; Jacobs & Callaghan, 2013).

Democrats enthusiastically support Medicaid expansion and always implement it

in the states in which they control the legislature and governorship. Republicans

are divided (Fording & Patton, 2019; Haeder & Weimer, 2015; Hertel‐Fernandez

et al., 2016; Rocco & Haeder, 2018), but much more likely to block expansion in

states in which they control the levers of government, especially if they are highly

influenced by ideology‐driven conservative groups (Hertel‐Fernandez et al., 2016;