The Politics of Medicaid Expansion: A Comparison of the Policy Debates in Arizona and Texas

Abstract

The Affordable Care Act, the health reform legislation passed in 2010, required all states to expand Medicaid to all those with incomes below 133 percent of the federal poverty line as a way to increase access to health coverage. In 2012, the Supreme Court, in NFIB v. Sebelius, upheld the constitutionality of the Affordable Care Act but ruled that the required Medicaid expansion was too coercive, effectively making Medicaid expansion a state option. Since then, 31 states plus Washington DC have chosen to expand. All Democratically-controlled states have already expanded Medicaid, meaning that future state debates over Medicaid expansion will take place within the Republican Party rather than across party lines. In the states that have not expanded Medicaid, a coverage gap exists, in which those who earn less than 100 percent of the federal poverty line do not have access to federal subsidies to help them purchase insurance on the exchange, but also do not meet their state’s current Medicaid eligibility criteria. Nearly three million Americans fall into this coverage gap and have no access to affordable health insurance. Most of who live in Southern states, controlled by Republicans, and are people of color. This thesis investigates the factors that influence a Republican-controlled state’s decision on Medicaid expansion. The thesis answers this question by comparing the political debates that have surrounded the issue in Arizona and Texas. Both Republican-controlled states with long histories of conservatism, Arizona expanded Medicaid, while Texas has not. This comparative analysis provides insight into the politics of Medicaid expansion in conservative states. In chapter two, I discussed the history of the Medicaid program as well as political science theories surrounding program containment and expansion. In chapter three, I outlined my methods of analysis. I used primary sources including press coverage and committee hearings, and I conducted personal interviews in order to investigate the policy debates that have taken place in each state. In chapter four, I analyzed the policy debate surrounding Medicaid expansion in Arizona. I found that policy entrenchment in the form of a previous coverage expansion that had taken place in Arizona was particularly influential. The previous expansion of Medicaid to all those making up to 100 percent of the federal poverty line and the freeze for the childless adults in that category that took place during the recession created a unique situation in which if Arizona did not expand Medicaid, tens of thousands of people would have lost their Medicaid coverage. This led to Governor Brewer’s full support for Medicaid expansion, which in turn brought in the business community to raise funds and lead a public relations campaign in support. This allowed the establishment wing of the Republican Party to pass Medicaid expansion over the strong objections of the Tea Party wing of the GOP. In chapter five, I analyzed the debate that has taken place in Texas. Texas has so far refused to expand Medicaid and the opposition of its political leadership, especially from first Governor Perry and currently Governor Abbott, has muted debate and lobbying efforts from provider groups and the business community. Texas had a less entrenched Medicaid program than Arizona had and the Tea Party has been a stronger force in Texas politics. Finally, I concluded with a comparative analysis in chapter six in which I flesh out the key differences between Arizona and Texas in their Medicaid expansion debates. The role of the Governor, the role of business and provider groups, and the relative power of the GOP establishment versus the Tea Party, were found to be the deciding factors in the two states’ divergence on Medicaid expansion.