Variation in Medicaid Administration and Corresponding Political Attitudes

• In Event: Policy Feedback and Public Opinion

Abstract

In March 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (hereafter, ACA) into law after it was passed by the 111th Congress. One of the key provisions of the ACA was a major revision and expansion of Medicaid eligibility, set to begin in 2014. In short, all citizens and legal residents with income up to 133% of the poverty line would qualify for Medicaid coverage in states participating in the expansion. Originally, if a state did not comply with the law, the federal government would withdraw all Medicaid funding to the state. However, in June 2012, the U.S. Supreme Court ruled the mandatory state Medicaid expansion unconstitutional, meaning states could choose whether or not to participate (National Federation of Independent Business vs. Sebelius, 567 U.S. 519, 2012). As of the November 2018 elections, 37 states including DC have adopted or voted to adopt the Medicaid expansion (Kaiser Family Foundation), and according to Medicaid.gov, 74.9 million people are currently enrolled in Medicaid or Children’s Health Insurance Program (CHIP), including 15.4 million Medicaid expansion adult enrollees (Nov 2017 and Dec 2016 figures, respectively).

Among states that have expanded Medicaid, the implementation has also varied, in part due to states applying for waivers covered under Section 1115 of the Social Security Act, which if approved allow “experimental, pilot, or demonstration projects that promote the objectives” of Medicaid and CHIP, giving states flexibility in program design (medicaid.gov/medicaid/section-1115-demo). As of November 2018, 46 such waivers had been approved across 38 states and 24 more are pending across 23 states (Kaiser Family Foundation Medicaid Waiver Tracker). In this paper, I exploit these cross-state differences in Medicaid expansion program administration. I ask: how do administrative choices affect the public’s perception of Medicaid? Using enrollment data from the Centers for Medicare and Medicaid Services and public opinion and program administration data from Kaiser Family Foundation and other sources, I build on the work of previous policy feedback research (e.g., Eric Plutzer’s 2010 Social Science Research Center Berlin’s discussion paper, Joe Soss’s 1999 APSR article) by studying the relationship between state-level program administration decisions and political attitudes holding the policy constant.

Author

• Meredith Dost, Harvard University