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

TLDR

The Affordable Care Act expands Medicaid to cover the uninsured, but as of August 2015, twenty states had not adopted expansion following the 2012 Supreme Court decision. The study seeks to explain why states choose to adopt or reject Medicaid expansion, especially in Republican‑led states. The authors use statistical modeling and case studies of Republican‑led states to examine how business associations and conservative networks influence Medicaid expansion decisions. The study finds that partisan differences drive expansion decisions, but within the Republican coalition, business associations can outweigh conservative networks, leading GOP‑leaning states to adopt expansion and illuminating current policy tensions.

Abstract

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.