The Political Context of Medicaid Expansion

Republican Congressional leaders are currently debating how to repeal the Affordable Care Act (ACA) as part of the budget reconciliation process. Much of the debate over the ACA has focused on the individual mandate (and here) and the affordability (here and here) of coverage in the state-based marketplaces. The House version of the legislation, however, includes a significant restructuring of federal funding for state Medicaid programs, which provide health insurance for low-income Americans. The bill slated for floor consideration later this week would achieve two major conservative goals: 1) reduce federal matching funds for non-elderly, non-disabled adults without dependent children; and 2) limit federal funds to a per-person amount, or per-state lump sum, at each state’s discretion. The non-partisan Congressional Budget Office has estimated that the bill would lead to 14 million fewer Medicaid enrollees and reduce federal Medicaid expenditures by $880 billion over 10 years.

The future of federal and state Medicaid policy will have personal implications for the 74 million people who are covered through their states’ programs, including the 14.6 million who have gained coverage under the ACA expansion.

A large amount of research has shown the expansion of Medicaid to newly eligible people [PDF] has been successful in increasing health insurance coverage and access to health care. Relative to states that have not opted to expand Medicaid coverage, expansion states have seen sharp increases in rates of insurance coverage and access to health care and projected decreases in racial disparities in coverage. Despite concerns about waiting times for new Medicaid beneficiaries to accesses providers, secret shopper research has shown that Medicaid patients are able to access health care in a timely manner. The ACA as a whole has remained a political flashpoint with sharply divided public opinion along party lines, although overall support for the ACA has increased this year. Medicaid policy is inexorably swept up in the political factors that are driving the current debate.

We were interested in understanding whether there was a correlation between state-level changes in insurance coverage under Medicaid expansion and states’ political ideology or presidential voting pattern. In particular, we thought that states with greater gains in insurance coverage among low-income adults might have had a more liberal political ideology or stronger support for Hillary Clinton in the 2016 election. To analyze this question, we first used the Behavioral Risk Factor Surveillance System (BRFSS) data to calculate the change in insurance coverage among non-elderly adults with incomes <100% FPL from 2011-2015 for each state. We then calculated the correlation between this change in insurance coverage and three different measures of state-level politics: 1) The percentage of voters supporting Hillary Clinton in the 2016 election; 2) A validated measure of state citizens’ ideology in 2013 (the most recent year available; where 0 is most conservative and 100 is most liberal);and 3) A validated measure of state elected officials’ ideology in 2013 (where 0 is most conservative and 100 is most liberal).

Here is what we found:

Note: Within-state correlations between change in insurance coverage between 2011-2015 among low-income individuals and percentage voting for the Democratic candidate in the 2016 election (rho=0.03). Does not include Washington, DC.


Note: Within-state correlations between change in insurance coverage between 2011-2015 among low-income individuals and validated measure of citizen ideology (rho=0.02). Does not include Washington, DC.

Note: Within-state correlations between change in insurance coverage between 2011-2015 among low-income individuals and validated measure of elected officials’ ideology (rho=0.24). Does not include Washington, DC.

There were increases in insurance coverage among low-income adults across all states. We found no correlation between an increase in insurance coverage and the percentage of the population that voted for Hillary Clinton (rho=0.03). We also found no correlation between rates of insurance coverage and the state citizen ideology being more liberal (rho=0.02). In contrast, we found a moderate correlation (rho=0.24) between the proportion of the population gaining coverage and the measure of state elected officials’ ideology. This suggests that a more liberal ideology among state elected officials, who made decisions about Medicaid expansion, is correlated with increases in health insurance coverage. Notably, there was a lack of correlation between state voting patterns or citizen ideology and changes in health insurance.

Our correlations may be informative in thinking about issue-based voting in the November 2016 election. Rather than ideology among individual voters in the state, the political ideology among political elected officials in the state was associated with whether the state expanded Medicaid.

Any plan to dismantle Medicaid as an entitlement program is likely to further impoverish low-income populations because coverage would not longer be guaranteed and fewer people would likely be eligible (leaving them at risk for medical costs). There is strong reason to believe that taking away federal Medicaid funds from the states under a block grant program would directly harm the health of tens of millions of pregnant women, children, individuals with disabilities, low-income Medicare beneficiaries and others in every state, particularly those that expanded Medicaid. It is our hope and expectation that Congressional leaders will continue to provide federal funds to support state Medicaid programs’ efforts to provide access to care for low-income Americans.

It is an empirical question whether voters will hold Republicans accountable in the wake of any actions that repeal Medicaid benefits without a comparable health program in place. It is not clear whether Medicaid expansion under the ACA has solidified a strong citizen constituency. This might be because Medicaid expansion was relatively recent; because individual citizens interact with Medicaid managed care insurers that they do not identify with the ACA; or because of a lack of solidarity across social classes in the United States.

Marian Jarlenski

Marian Jarlenski

Marian Jarlenski, PhD, MPH, is an Assistant Professor in the Department of Health Policy and Management in the University of Pittsburgh Graduate School of Public Health. Her research seeks to advance knowledge about how health policies affect access to care, clinical practice, and health behaviors that ultimately affect maternal and child health outcomes. Current work focuses on how health policies can be optimized to improve the health of women who use substances in the perinatal period. Dr. Jarlenski is an expert in Medicaid policy and is interested in the politics of health policy. She earned a PhD from the Johns Hopkins Bloomberg School of Public Health, an MPH from the Yale School of Public Health, and a BA from Otterbein College.
Marian Jarlenski

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