To Expand or Not Expand Medicaid? That is the Republican Governor’s Question Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Wesley Prater Graduate Program in Public Health The Ohio State University 2018 Dissertation Committee Sandra Tanenbaum, PhD Advisor Tasleem Padamsee, PhD Deena Chisolm, PhD Thomas Nelson, PhD 1 Copyrighted by Wesley Spencer Prater 2018 2 Abstract The June 2012 Supreme Court decision concluded that all provisions of the Affordable Care Act were constitutional except for the mandatory Medicaid expansion for adults. Therefore, each state had the option to expand Medicaid. By 2015, thirty-one states had adopted Medicaid expansion. Medicaid expansion is generally supported by Democrats and resisted by Republicans. Given the power governors have in Medicaid policymaking, it would stand to reason that states with Democratic governors would expand while states with Republican governors would not. However, ten states adopted expansion with a Republican governor. In the context of widespread Republican opposition to the ACA, why did some Republican governors support Medicaid expansion? What factors influence Republican governors’ decisions regarding Medicaid expansion? The overall goal of this study is to understand the conditions under which Republican governors decided to support Medicaid expansion, given their party’s opposition. Using mixed methods, the specific aims of this study are: 1) Identify the factors associated with a Republican governor’s decision to support Medicaid expansion. ii 2) Determine in-depth how these factors and perhaps others, interacted with Republican governors in two states – one expansion state (Arizona) and one non- expansion state (Florida). The results from this study imply that in the case of Medicaid expansion, ideological, economic, political, and racial factors influence the decision-making of Republican governors, with ideological factors being the most dominant. The implications of this study are extensive for stakeholders including policymakers, public health advocates, interest groups, and researchers in states with Republican governors. It offers statistical and qualitative data that can be used to help them identify potential problems and solutions for coverage expansions in the future in seemingly challenging circumstances. Moreover, findings from this study can help stakeholders in favor of Medicaid expansion illuminate the conditions in which coverage expansion may be difficult or relatively easy as well as help them explain why. Learning more about what drives expansion of coverage in challenging circumstances is important as these expansions contribute to making health care more accessible, equitable, and affordable, particularly for low-income and vulnerable populations. iii Dedication I dedicate this to my wife, daughters, parents, and grandparents. iv Acknowledgments I give thanks to God first for blessing me with this opportunity and the ability to fulfill my purpose in life. My prayers were always answered throughout this challenging journey. I must give a special thanks to my advisor and committee chair, Dr. Sandra Tanenbaum. I greatly appreciate all of the time, energy, and care you have given me from my first semester to my last. You have been my advocate. It has truly been a privilege to learn so much about policy, politics, and life from you. I cannot thank my remaining committee members enough for all of their support during this dissertation process. I learned a great deal from each one of you over the years. I gained a passion for qualitative work through Dr. Tasleem Padamsee. My knowledge of Medicaid and quantitative analysis expanded under Dr. Deena Chisolm. Dr. Tom Nelson enlightened me in the field of political science from experimental design to survey design. You all have been instrumental in my growth as a scholar. Thank you to everyone in the College of Public Health for your mentorship, financial support, and teaching. A special thank you to Dr. Thomas Wickizer and Dr. Eric Seiber for convincing me to attend The Ohio State University College of Public Health. Also, a special thanks to Kynthia Droesch, Elizabeth Hope, and Renee Watts for v helping me with logistics and deadlines. You all made things much easier for me, whether you realized it or not. Thank you to my only other cohort member, Taleed El-Sabawi, for navigating and tackling all of the Ph.D. courses with me. We made it! Also, thank you to Naomi Adaniya, Tiasha Letostak, Marika Paul, Laura Prater, and Chris Wilks, all of whom gave me advice on how to be successful in this program. I must also thank my mentors and former colleagues at the Center for Mississippi Health Policy and Georgetown CCF. A special thanks to Therese Hanna, Joan Alker, Amy Radican-Wald, and Peggy Honoré. Each one of you provided me with a unique opportunity to gain real-world health policy experience, and I gained so much knowledge from working with each one of you. To Malcolm, Denise, Brian, and Shawna, a special thank you for your hospitality and support while conducting interviews. To my Aunt Dora and Uncle “Simp,” thank you for always giving me a place for comfort, laughter, and love while being a doctoral student. To my extended family, in-laws, and close friends, thank you for your words of encouragement and support. To my sister, thank you for always having my back. Your decision to go back to school with all of your responsibilities was truly inspiring! I have always appreciated your continued support and love. To my parents, I learned about the importance of education by your examples, and that always motivated me to go back to graduate school. You also taught me about vi sacrifice, determination, and faith – all of which were necessary for me to succeed in this program. You have always been supportive of my educational journey. More importantly, you have always been supportive of my journey of life. You are undoubtedly the best parents a son could have. Lastly, I want to thank my immediate family. You all motivated me day-in and day-out and balanced me throughout this experience. To my daughters, Baleigh and Lily, thank you for bringing me joy, laughter, and love over the past few years. I love you both unconditionally. Hopefully, I made you proud. To my wife, Rhea, there are not enough pages in this document that can express my gratitude. You have sacrificed more than me over the past four years, and it never went unnoticed. Thank you for the pep talks, thank you for your love, and thank you for always believing in me. Simply put, you are my rock. The dissertation and degree are just as much yours as they are mine. I love you! vii Vita 2004…………………………………………………B.S. Chemistry, Jackson State University 2006…………………………………………………M.P.H. Health Policy and Administration, Yale University School of Public Health 2006-2011………………………………………….. Policy Analyst, Center for Mississippi Health Policy 2011-2014…………………………………………...Senior Health Policy Analyst, Georgetown University Health Policy Institute, Center for Children and Families 2014-2018…………………………………………...Susan L. Huntington Dean’s Distinguished University Fellow, College of Public Health, The Ohio State University viii Fields of Study Major Field: Public Health Minor Fields: Political Science and Public Policy and Management ix Table of Contents Abstract ............................................................................................................................... ii Dedication .......................................................................................................................... iv Acknowledgments............................................................................................................... v Vita ................................................................................................................................... viii List of Tables .................................................................................................................... xii List of Figures .................................................................................................................. xiii Chapter 1. Introduction ....................................................................................................... 1 Background ..................................................................................................................... 1 Medicaid Expansion and the Affordable Care Act ......................................................... 2 Mechanisms for State Medicaid Expansions .................................................................. 5 Governors and Medicaid Expansion ............................................................................... 6 Specific Aims ................................................................................................................ 11 Chapter 2. Literature Review ............................................................................................ 12 Chapter 3. Theoretical Justification of Variables and Hypotheses .................................. 17 Ideological Pressures .................................................................................................... 20 Economic Pressures ...................................................................................................... 25 Political Pressures ........................................................................................................