The Distributive Politics of Implementation: Governors and the Medicaid Expansion
The June 2012 Supreme Court decision on the Affordable Care Act (ACA) granted states the option to not participate in the Medicaid expansion and retain their current eligibility rules. Governors’ role in implementing national policy initiatives at the state-level grants them considerable influence over whether states’ expand their Medicaid eligibility. Accordingly, their decisions to support or oppose the expansion should clear have political motivations given their potentially far-reaching policy consequences. Yet, governors’ opposition to the Medicaid expansion does not fall strictly align with partisan leanings – several Republicans support the expansion – or public opinion. Alternative explanations for governors’ opposition or support include state financial consequences and constituent need, respectively. Opponents stress that the burden from additional Medicaid beneficiaries exacerbates already dire financial landscapes, yet only half of the dissenting governors faced budget gaps. Alternatively, supporters often point to greater constituent need from higher levels of poverty and rates of uninsurance; yet, states with some of the highest numbers of potential beneficiaries face gubernatorial opposition.
What is driving the decision to oppose this constituent-centered, federally-funded health policy? In this paper, I argue that the answer begins with recognizing how these potentially eligible beneficiaries overlap with governors’ electoral constituencies, providing a clear opportunity to engage in distributive politics. While much of distributive politics research focuses on legislative allocations of public spending across distinct, geographically-defined cleavages, this paper turns to the executive’s role.
Specifically, I argue that income segregation and income-based eligibility requirements, and the right to refuse implementation, transform Medicaid expansion benefits into a tactical distributive policy. If eligible beneficiaries (those with incomes less than 138 percent FPL) are distributed such that supporting counties will benefit at least as much as opposing ones, then the expansion presents an opportunity for governors to deliver benefits to electorally relevant constituencies. However, if beneficiaries are concentrated in opposing counties where the governor lost by a wide margin, it is not likely to improve re-election chances. Thus, I contend that governors strategically support (oppose) implementation when their supporters will (not) receive the bulk of the benefits, thus rendering it (less) electorally valuable.
To determine whether distributions of potentially eligible beneficiaries and electoral supporters are statistically significant from each other, I use non-parametric Kolmogorov-Smirnov (KS) two-sample tests to calculate the maximum difference in the empirical cumulative distribution functions. I find that governors who oppose the expansion face statistically different distributions of eligible populations between the counties where they won or lost by wide margins. Specifically, in these states, electorally supportive counties have significantly smaller distributions of eligible beneficiaries compared to unsupportive ones. Alternatively, governors who support the expansion face statistically indistinguishable distributions of eligible beneficiaries across counties, such that supporting counties benefit at least as much as opposing ones.
Incorporating elements of distributive politics and sociological research on income segregation with health policy implementation pushes back on our conventional wisdom that policies are distributive only by design. The changing socio-economic landscape of 21st century communities indicate that the benefits of health and welfare policies are subject to both legislative design and executive implementation. When we think about Medicaid expansion benefits as distributive in implementation, then we might better address how to ensure that their objective, to increase coverage for low-income uninsured Americans, is more consistently met.