Medicaid, Race, and Local Discretion: How Segregation Affects Benefit Allocation

• In Event: Who Uses Public Health Resources and Who is Seen as Deserving of Doing So

Abstract

This study shows how segregation and bureaucratic discretion affect the distribution of state Medicaid resources. There have been huge changes in the structures of state Medicaid programs especially since the passage of the Affordable Care Act, with states taking different approaches. There are federal guidelines and funding, but states customize their own programs within these guidelines. Then, counties are the ones charged with implementation, i.e. citizen enrollment and benefit administration. The amount of bureaucratic discretion states leave to welfare agencies through their Medicaid policy and county-level context affect how programs are administered, who is enrolled in the program, and thus who can afford healthcare. Bureaucratic discretion does not necessarily lead to similar outcomes for individuals across race and class. I use text analysis of state Medicaid policies to measure the amount of discretion welfare agencies are granted, and I use Medicaid enrollment data and Census demographic data from all 3,100 U.S. counties to measure Medicaid allocation relative to need and county characteristics. I estimate a multilevel model and show that Medicaid resources are disbursed disproportionately. In counties that are highly heterogeneous by race, there is lower Medicaid enrollment relative to need. The enrollment to need ratio is also lower in states with more restrictive Medicaid policies and in states that have not expanded Medicaid.

Author

• Tracee Morgan Saunders, University of Iowa