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The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making

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The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Sandoe, Emma. 2019. The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making. Doctoral dissertation, Harvard University, Graduate School of Arts & Sciences. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:42029469 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making A dissertation presented by Emma Sandoe to The Committee on Higher Degrees in Health Policy in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the subject of Health Policy Harvard University Cambridge, Massachusetts May 2019 ! ! © 2019 Emma Sandoe All rights reserved. ! ! Dissertation Advisor: Professor Robert Blendon, Sc.D. Emma Sandoe The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making Abstract Health insurance coverage and politics are intertwined. This dissertation will examine how voters respond when there are changes to health care policies, why state legislatures and state executives act to address health care workforce shortages, and how interest groups utilize the political system to effectively pass policies. Chapter 1 evaluates the effect of coverage expansion on voter participation. One of the recognized benefits of increased health coverage is that it leads to improved financial wellbeing for beneficiaries. With improved financial status individuals may be more likely to engage in activities that previously had access barriers. One potential barrier that health insurance may alleviate is the barrier to voting. This paper will address 1) whether improved health insurance coverage and availability of Medicaid creates the observed effects; 2) whether improved voting participation resulted following the expansions of health insurance coverage; and 3) whether there is a threshold at which coverage expansions no longer effect voting behavior. We examine two states, Massachusetts following the 2006 coverage expansions and Florida following the 2014 coverage expansions. Chapter 2 examines the political conditions necessary for states to act to increase home care worker wages. Home care workers are among the largest and fastest growing segments of low-wage workers. In many states home care workers earn near hourly minimum wage. Medicaid is the primary payer for long-term care services and services provided in the home and community settings by home care workers. Medicaid’s large share of the home care market ! """!! implies that policy made by a state Medicaid program could have a significant effect on home care worker wages in the private market. In recent years, state legislatures have taken actions to increase the wages for home care workers in the Medicaid. We examined 48 attempted wage increases and 34 successful wage increases from 2013-2018 to determine what political factors increase the likelihood that a state will increase home care worker wages. Union membership in the state, females in the legislature, and more professional legislatures were associated with increases to home care worker wages. Chapter 3 evaluates the changing role of direct democracy in health policy using Medicaid expansion as a case study. From November 2017 through November 2018 four states voted to expand through ballot initiative and only one voted to expand Medicaid through the legislature. Why have states decided to use this method of policy making, instead of passing the law through the legislature and governor? Setting Medicaid eligibility through direct democracy represents a growing change in how health policy is made in states and how ballot initiatives are used to change health care programs. The four Medicaid expansions are representative of this shift in method of policy making and were a way to overcome legislative obstructions through the traditional policy processes in states. These ballot initiatives passed because Medicaid expansion is popular among voters, interest groups advocating for these changes were well organized and funded, and they utilized local and national organizations to influence voters. ! "#!! Table of Contents Abstract………………………………………………………………………………. iii Acknowledgements……………………………………………………………………vi Chapter One …………………………………………………………………………. 1 Health Care on the Ballot: The Role and Limits to Health Insurance Coverage in Voting Chapter Two ………………………………………………………………………… 36 Why States Raise Wages: Politics and Home Care Worker Wage Increases Chapter Three ………………………………………………………………………...63 The Increasing Role of Direct Democracy in Health Policy: Medicaid Expansion Ballot Initiatives in the 2017 and 2018 Elections Appendix………………………………………………………………………………114 Bibliography…………………………………………………………………………..121 ! #!! Acknowledgements The support and encouragement of my dissertation committee was fundamental to the competition of this dissertation. Robert Blendon has provided me with the insight and wisdom on health politics throughout my career at Harvard. His advice and guidance have provided me with clear and prudent direction both academically and through forging my career in health policy. Richard Frank’s immense knowledge on health economics, quantitative methods, and issues of long-term care and issues related to mental health and addiction have been invaluable to my research both in this dissertation and elsewhere. Andrea Campbell has provided me with countless amounts of insight and valuable advice on my writing. Don Berwick has been a mentor and his attention to detail and the broader questions in my writing has improved my writing. All of my advisors have had faith in my ability and have pushed me succeed. I am so grateful to the time that they have invested in me and my work. They have been role models to me for years prior to asking them to join my committee and I feel honored that their names appear next to mine. Faculty from across the university have served as mentors and advisors. I have benefited from being a part of 11 teaching teams where I had the opportunity to work closely with faculty. Richard Parker, Haiden Huskamp, Ateev Mehrotra, David Grabowski, and David Cutler have all taught me how to serve as a better instructor. Generous funding was provided by these teaching teams as well as the Agency for Healthcare Research & Quality (AHRQ) Graduate Fellowship. Kathy Swartz and Benjamin Sommers have been wonderful advisors and mentors throughout my time at Harvard and people whom I hope to emulate in my research work. My time at Harvard was made rich by my fellow students. I owe a massive debt of gratitude to Adrian Garcia Mosqueira who has given me the strength and support to complete the ! #"!! program. He has repeated ad nauseum “you can do this” over the last five years whenever I needed it the most. His friendship has not only made this process stronger academically, his companionship has made this process enjoyable. Mary Gorski has been a source of inspiration and encouragement throughout my time at Harvard and has dealt with my endless questions and fears. Her kindness and patience go unrivaled. Carrie Fry, while two years behind me in the program, is someone who I look up to both academically and personally. She has helped me through thorny coding issues and anxiety about the larger life questions and for that, I am in her debt. Michael Anne Kyle’s strong will and determination have guided me to achieving more than I knew I could do. Thalia Porteny, Annabelle Fowler, Savannah Bergquist, Christine Baugh, Julia Dennett, Kate Lofgren, Maryaline Catillon, Vidit Munshi, Peter Dyrud, Aroop Mukharji, and Sarah James have all helped me navigate this PhD and I cannot wait to see how their work changes the world. The Political Analysis track cannot be thanked enough for the support and encouragement of my fellow students including Ali Hamandi, Joe Hero, Loren Saulsberry, Kirstin Scott, Alee Lockman, Adrianna McIntye, and Caitlin McMurtry. A special thank you goes to the Health Policy PhD program staff. Debbie Whitney and Colleen Yout have given me a community and have provided me with both candy and comfort on a nearly daily basis. Thank you also to Justin Sayde who has supported me and provided me with too many numerous printing and room reservation favors over the years. Thank you to my community of friends outside of the PhD program that have supported me and helped me through this period in my life where I’m sure I haven’t been my best self. Ginny Joseph has supported me by both letting me practice presentation after presentation and through her unquestionable friendship. Jason Millman has given so much time to editing my ! #""! ! writing as well as patiently listening to my complaints. To all of my other friends and community that have supported me, thank you and your kindness does not go unnoticed. Mom and Dad, I owe you everything. You both have always had a strong sense of justice and fairness. You have given me the moral courage to fight for the rights of those who cannot fight for themselves. You have taught me the importance of health by serving as my own
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