Business Associations, Conservative Networks, and the Ongoing Republican War Over Medicaid Expansion

• Published in: Journal of health politics, policy and law policy and law, 2016-04, Vol.41 (2), p.239-286
• Main Authors: Hertel-Fernandez, Alexander, Skocpol, Theda, Lynch, Daniel
• Format: Article
• Language: English
• Subjects: Associations; Business; Case studies; Choices; Commerce; Court decisions; Decisions; Economics; Expansion; Government programs; Governors; Health; Health care; Health care policy; Health Care Reform - legislation & jurisprudence; Humans; Intellectuals; Legislation; Mathematical models; Medicaid; Medicaid - legislation & jurisprudence; Medicaid - organization & administration; Medicine and Health; Networks; Participation; Partisanship; Patient Protection & Affordable Care Act 2010-US; Patient Protection and Affordable Care Act; Political parties; Politics; Public Health and Health Policy; Public Policy; Reforms; Social networks; State Government; State laws; Statistical models; Studies; Supreme Court Decisions; Trade associations; Uninsured people; United States; War
• ISSN: 0361-6878; 1527-1927
• DOI: 10.1215/03616878-3476141

A major component of the Affordable Care Act involves the expansion of state Medicaid programs to cover the uninsured poor. In the wake of the 2012 Supreme Court decision upholding and modifying reform legislation, states can decide whether to expand Medicaid—and twenty states are still not proceeding as of August 2015. What explains state choices about participation in expansion, including governors' decisions to endorse expansion or not as well as final state decisions? We tackle this puzzle, focusing closely on outcomes and battles in predominantly Republican-led states. Like earlier scholars, we find that partisan differences between Democrats and Republicans are central, but we go beyond earlier analyses to measure added effects from two dueling factions within the Republican coalition: statewide business associations and cross-state networks of ideologically conservative organizations. Using both statistical modeling and case studies, we show that GOP-leaning or GOP-dominated states have been most likely to embrace the expansion when organized business support outweighs pressures from conservative networks. Our findings help make sense of ongoing state-level debates over a core part of health reform and shed new light on mounting policy tensions within the Republican Party.