Medicaid Expansion and the States: Implementation, Politics, and the Affordable Care Act by Phillip M. Singer A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Health Services Organization and Policy) in the University of Michigan 2018 Doctoral Committee: Professor Scott L. Greer, Co-Chair Assistant Professor Holly Jarman, Co-Chair Professor Nicholas Bagley Professor Barry Rabe Professor Charles C. Ragin Phillip M. Singer [email protected] ORCID iD: 0000-0003-4067-0829 © Phillip M. Singer 2018 Dedication For Jennifer, Felix, and Edith for being my “still point of the turning world.” ii Acknowledgements I came to the University of Michigan in the Fall of 2011 after being accepted into the Masters in Health Services Administration program. Seven years later I not only have received my Masters but a PhD from the greatest University in the world. These past seven years have been humbling, enriching, and rewarding. I am incredibly grateful for all of the support that I have received from the faculty in Health Management and Policy. In particular, during my Masters training, I want to thank Dr.’s David Mendez, Richard Hirth, and Christy Lemak. Each of you supported and encouraged me to continue my education in the doctoral program. Without your guidance, support, and kindness I would not have even started on this journey. Any success that I have had during my time in the doctoral program has been a result of the people that I have collaborated with and learned from. Most prominently are my dissertation co-chairs Dr.’s Scott Greer and Holly Jarman. I cannot imagine more supportive and helpful mentors. Additionally, I have been blessed with an outstanding committee. Professor Nicholas Bagley, Dr. Charles Ragin, and Dr. Barry Rabe, each have provided incredible insights and helped improve this project. I have learned much from my encounters with them, both academically and professionally. It truly takes a village and I would not have had a modicum of success without Mindy Niehaus-Fukuda, Tyra Sampson, Kaitlyn Taylor, and Brenda Bernhardsson. For the past three years I have had the unbelievable opportunity to work with Dr. Angela Beck and the rest of the Behavioral Health Workforce Research Center here at the iii University of Michigan. Dr. Beck, as well as Jessica Buche and Cory Page have nurtured and supported me in more ways then they know. My experiences in Health Services, Organization and Policy would not be complete without the friendships and collaborators I have met and will continue to work with from this program. I met David Jones my first week after moving to Ann Arbor and he has been far more generous in his time and efforts than I deserve. His friendship has been invaluable and I look forward to continuing to work together. Charley Willison has always lent an optimistic ear during doubts and challenges. Michael Rozier has been a wonderful collaborator and friend. I also want to thank each of the individuals in my cohort: Betsy Cliff, Dori Cross, Zach Levinson, John Richardson, and Sasha Zhou. I count myself lucky to have been able to associate with you over the past five years. I look forward to following each of your careers as you continue your interesting and important work. Lastly, I want to thank the residents of M3331, Betsy Cliff, John Richardson, and Qing Zheng. Dissertating is not easy, but sharing an office with each of you made my day a little brighter and a little better. Lastly, I would never have been able to accomplish anything without the loving support of Jennifer, Felix, and Edith. At the end of even the most discouraging day, I would come home to hugs, kisses, Legos, and Barbie’s. Every morning I would write out my list of things I needed to do during the day and I would always start my list by writing down a short phrase from T.S. Eliot from his Four Quartets: “at the still point of the turning world”. Regardless of what was happening around me, the challenges, stress, and disappointment that I might face, you three have always been and will always be the still point by which my world rotates around. Thank you for your support, your patience, and your sacrifices you have made for me. iv Table of Contents Dedication .................................................................................................................................. ii Acknowledgements ................................................................................................................... iii List of Tables ............................................................................................................................ vi List of Figures .......................................................................................................................... vii List of Appendices .................................................................................................................. viii Abstract ..................................................................................................................................... ix Chapter 1: Medicaid Expansion and the States ........................................................................... 1 Chapter 2: How We Got Here or Theories of Federalism, State Decision-Making, and Partisanship in the United States ............................................................................................... 21 Chapter 3: Methods: Case Selection, Interview Guides, and Document Analysis ...................... 47 Chapter 4: National Results from fsQCA Analysis ................................................................... 74 Chapter 5: Utah: Intra-Party Divisions, Policy Entrepreneurs, and Failed Expansion ................ 88 Chapter 6: Arizona: Policy History, Institutional Design, and Strategic Actors ........................139 Chapter 7: Michigan: State Finances, Inter-Party Divisions, and Waivers ................................180 Chapter 8: Themes from across the Case Studies .....................................................................222 References...............................................................................................................................241 APPENDICES ........................................................................................................................290 v List of Tables Table 1:1 Supreme Court Decisions on ACA Medicaid Expansion ........................................... 12 Table 1:2 Gubernatorial Party and Expansion Decision ............................................................ 16 Table 1:3 Timing of Expansion ................................................................................................ 17 Table 2:1 All Federal expansions of Medicaid coverage prior to ACA ...................................... 34 Table 3:1 Variables for fsQCA Analysis................................................................................... 50 Table 4:1 Data Matrix for States ............................................................................................... 76 Table 4:2 Truth Table ............................................................................................................... 78 Table 4:3 Necessary Conditions for Medicaid Implementation ................................................. 79 Table 4:4 Causal Pathways Identified Through fsQCA ............................................................. 80 Table 4:5 Causal Pathways from fsQCA Sensitivity Analysis ................................................... 82 Table 7:1 Partisan Control over Legislature and Executive Office in Michigan ........................182 Table 7:2 Timeline of 2013 Waiver States ...............................................................................184 Table 7:3 Components of Select Waiver Expansion States ......................................................184 Table 7:4 House of Representatives Voting on House Bill 4714 ..............................................199 Table D:1 Interviewing Coding Protocol .................................................................................312 Table E:1 Document Coding Protocol .....................................................................................314 vi List of Figures Figure 2.1: Political Party Polarization ..................................................................................... 30 Figure 2.2: Partisanship and Health Reform.............................................................................. 31 Figure 7.1. Uninsured and Tax Revenues in MI .......................................................................181 Figure 7.2: Campaign Contributions ........................................................................................186 Figure 7.3: Gov. Rick Snyder’s Travels 2013 ..........................................................................203 vii List of Appendices APPENDIX A: Codebook FSQCA Variables ..........................................................................291 APPENDIX B: Consent for Participation in Interview Research ..............................................303 APPENDIX C: Interview Protocol Form .................................................................................305 APPENDIX D: Interview Coding Protocol ..............................................................................312 APPENDIX E: Document Coding Protocol .............................................................................314 viii Abstract When the Supreme Court held in