Representation and Health Policy in 50 States and 7,383 Districts

• In Event: Issues in Representation and State Politics

Abstract

Just a week ago, enough Kansas Republicans switched their positions to ensure the passage of a proposal to expand Medicaid. The same happened last year in Montana. Surprise billing laws are totally frozen in Congress, but they’ve been enacted into law in 28 states, including Texas. In California, a single payer bill was tabled by House Democrats after passing the Senate.

These seemingly surprising decisions by individual legislators in specific districts call out for analysis. While state capitols are the site of much of the action, so too is the district-by-district contest to push for health policy changes. Similarly, while interparty dynamics between Republicans and Democrats are important, yet many of the policy reforms are being hashed out in the context of intraparty debates and single-party states. Yet we know very little about how policy is developed at the district and intraparty levels.

How well do the unsung workhorses of American representative democracy--its thousands of state legislators--represent their constituents on the most vital issues of the day? Are the decisions they make in the statehouse reflective of the wishes and needs of their constituents, or do other influences--their own preferences, those of their party, and those of particularized interests--hold more sway? This question is particularly important in understanding the thoroughly politicized domain of health care.

I identify five relevant influences on state legislators in their bill introductions, sponsorship, committee action, and roll call voting behavior. Do more liberal views by district constituents on pressing health care concerns predict more liberal voting patterns by their representatives in the statehouse? Do objective measures of need -- specifically measures of poverty and health insurance coverage -- also predict such patterns? Or are such variables overridden by legislators' own ideological preferences or partisanship? What role do particularized interests--both of the ideological and economic interest varieties--play in influencing legislators?

Whether elected representatives' behavior is congruent with constituent opinion and policy needs is a fundamental inquiry in a representative democracy, and has been a major touchstone in the research on American politics. However, earlier work concentrates on representation at the federal level. When states are studied, it is almost entirely in statewide terms. Finally, representation is understood in general ideological terms rather than in specific policy areas like health. In short, we know very little what happens in the states, in terms of specific policies, and at the district level because of measurement difficulties. This project would address those issues by the use of new data and new techniques. Bringing these together would allow us to understand how and when viable coalitions to implement (and delay) Affordable Care Act implementation in the states.

In Shor 2018, I identified several dozen roll calls on three facets of state implementations of the ACA (state health insurance exchanges, Medicaid expansion, and individual mandate nullification). I intend to massively expand this data by collecting over 23,000 roll calls related to health care reform from 2009-2019, with over 1.5 million votes by more than 13,000 legislators. Only a small number of votes have generated headlines, so there are huge differences in salience that might be relevant. This much statistical power will allow me to perform analyses impossible with smaller data sets.

The primary outcome variable of the first paper will be the legislative behavior of state legislators. Thanks to funding from the Russell Sage Foundation, I will be conducting an original survey to provide the public opinion data to assess representation. I will collect tens of thousands of responses to provide sufficient data for multilevel regression and poststratification (MRP) estimates to be generated at the state legislative district level (Warshaw and Rodden 2012). I will also collect interest group data on the ideological preferences and locations of physicians nationwide (from Adam Bonica). Legislator ideology data is from my updated data set (Shor and McCarty 2011) through 2019.

Author

• Boris Shor, University of Houston