Medicaid Expansion in the United States: A State Comparative Study Examining Factors that Influence State Decision Making

Abstract

Since the passage of the Patient Protection and Affordable Care Act (ACA) and a Supreme Court ruling that the federal government cannot compel states to expand Medicaid, a policy window has opened for states to change Medicaid policy. States are now faced with the option to expand Medicaid. Although the literature on Medicaid expansion indicates that politics plays a determining role on states' decisions on Medicaid expansion, comprehensive analyses of dominant factors that affect these decisions on Medicaid is lacking in the field of Medicaid policy. This study will explore the decision making process of state level policies and the effect of relevant state characteristics on Medicaid expansion. This dissertation examines prominent factors that influence state decisions on Medicaid expansion. Although the literature on Medicaid expansion post the ACA is limited in scope, this study is informed by a range of other disciplines, such as education, political science, intergovernmental management, and economics. A conceptual framework is developed based on the interdisciplinary nature of the literature and five models are created: political, economic, needs-based, state capacity, and state innovation and diffusion. A state comparative cross-sectional research design is utilized to test the five models and a combined model of state decision making on Medicaid expansion using multinomial logistic regression analysis and descriptive statistics. The results of this study reveal that when all of the models are combined, state needs-based factors are more influential than political, economic, state capacity, and state innovation and diffusion factors. However, the political model has the most explanatory power when the individual models are tested separately. This research demonstrates that the five models utilized in this study play a significant role in the decision making process of states on Medicaid expansion. In addition, this research addresses a gap in the literature that elucidates influential factors that affect the decisions of states on not only Medicaid policy, but also general state policies.