THE POLITICS OF EXPANDING MEDICAID IN REPUBLICAN-LED STATES: LESSONS FROM ARIZONA, INDIANA, AND TENNESSEE David Adler A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Public Health in the Department of Health Policy and Management in the Gillings School of Global Public Health. Chapel Hill 2018 Approved by: Jonathan Oberlander Aaron McKethan Pam Silberman Rebecca Slifkin Michael Sparer © 2018 David Adler ALL RIGHTS RESERVED ii ABSTRACT David Adler: The Politics of Expanding Medicaid in Republican-led States: Lessons from Arizona, Indiana, and Tennessee (Under the direction of Jonathan Oberlander) This study examined the question of why some states led by Republicans expanded Medicaid to 138% of the federal poverty level as allowed by the Affordable Care Act, while nationally most Republican governors and legislatures resisted expansion. Through in-depth case studies, I explored how policymakers and stakeholders addressed Medicaid expansion in Arizona, Indiana, and Tennessee. While all three states studied are unique, I identified six themes that influenced the Medicaid expansion decision in each of the states: prior Medicaid history in the state, the relationship between the governor and legislature, the language used to discuss Medicaid expansion, stakeholder coalitions, the political environment, and federal-state negotiations. The state’s previous history of Medicaid policy emerged as the most influential factor shaping state decisions, with states that had previous popular expansions being more ready to expand. Negative experiences, such as restricting coverage expansions under TennCare, left a lasting legacy that proved impossible to overcome. Other important factors that facilitated Medicaid expansion in GOP-led states included having a governor who was an advocate and knew how to work with a legislature, conservative voices speaking in favor of expansion, and hospitals willing to pay an assessment to cover the cost. iii This work informs a plan for how the Robert Wood Johnson Foundation can more effectively work to influence policy at the state level by finding ways to engage a more diverse set of stakeholders and by working to engage more people in voting activities to ensure their preferences are heard in the policy process. iv For Cole, who had the dubious distinction of being a deputy dean at home and at work for the past four years. v ACKNOWLEDGEMENTS I am extremely grateful for the guidance and support of so many people who made my dissertation possible. I thank my advisor, Jonathan Oberlander, for his steady guidance and encouragement. Jon helped me clarify my thinking and writing and made this project so much stronger. Aaron Mckethan, Pam Silberman, Rebecca Slifkin, and Michael Sparer were an outstanding committee whose insightful feedback and questions gave this project new depth. I am also grateful to Sandra Greene, who endowed a scholarship that I was fortunate to receive. I would never have started a doctoral program, much less finished one, without the support of the Robert Wood Johnson Foundation, where I have been lucky enough to work for the past nine years. John Lumpkin encouraged me to pursue this degree, and Anne Weiss was my patient boss while I worked and went to school at the same time. My dear friend and colleague Andy Hyman passed away while I was in school. He taught me so much about Medicaid and life. In addition to the financial support the institution provided, so many colleagues provided emotional and intellectual support along the way that it would be impossible to thank them all, but I will always be grateful. Of course, I would never have finished this dissertation without the support of my family. My mother, Joan Adler, and my father and stepmother, Jan and Doris Adler, were supportive and reassuring at every step. But really, my husband Cole had the hardest job of all: living with me vi while I went to school and worked full time. I will always be grateful for his support and understanding as I went through the ups and downs of writing a dissertation. vii TABLE OF CONTENTS LIST OF TABLES ....................................................................................................................... xiii LIST OF ABBREVIATIONS ...................................................................................................... xiv CHAPTER 1: INTRODUCTION .................................................................................................. 1 CHAPTER 2: LITERATURE REVIEW ........................................................................................ 5 Search Methods and Inclusion/Exclusion Criteria ...................................................................... 5 Results ......................................................................................................................................... 7 How did state-level political and stakeholder dynamics shape Medicaid policy decisions prior to the ACA? ......................................................................................... 7 How have state-level political and stakeholder dynamics shaped ACA implementation? ... 13 How have state-level political and stakeholder dynamics shaped decisions to expand Medicaid under the ACA? ........................................................................................ 15 Discussion ................................................................................................................................. 18 CHAPTER 3: METHODOLOGY ................................................................................................ 22 Case Selection ........................................................................................................................... 22 Data Collection .......................................................................................................................... 25 Analysis ..................................................................................................................................... 27 Limitations ................................................................................................................................ 29 CHAPTER 4: ARIZONA ............................................................................................................. 32 viii Sebelius v. NFIB Meets Proposition 204 .................................................................................. 32 Building Support for Expansion ................................................................................................ 34 The Governor Decides to Expand ............................................................................................. 37 The Fight ................................................................................................................................... 40 Post Enactment .......................................................................................................................... 46 Analysis ..................................................................................................................................... 47 Governor. ............................................................................................................................... 47 Legislature. ............................................................................................................................ 47 Coalition. ............................................................................................................................... 48 Political environment............................................................................................................. 48 Language and framing. .......................................................................................................... 49 Federal-state negotiation and previous history. ..................................................................... 49 Conclusion ................................................................................................................................. 50 CHAPTER 5: INDIANA .............................................................................................................. 51 Healthy Indiana Plan ................................................................................................................. 51 Mitch Daniels and the Affordable Care Act .............................................................................. 52 Pence and Medicaid Expansion................................................................................................. 54 The Governor and the Legislature ............................................................................................. 54 Coalition Politics and Moving Forward on HIP 2.0 ................................................................. 56 Negotiations with CMS ............................................................................................................. 62 ix Analysis ..................................................................................................................................... 65 Governor and legislature. ...................................................................................................... 65 Previous Medicaid history and language. .............................................................................. 65 Coalition and federal-state negotiations. ..............................................................................