The elephant in the room: why some states are refusing to expand Medicaid

Abstract

After the US Supreme Court overturned the Affordable Care Act’s mandate that states expand Medicaid, roughly half the states have declined to expand. Declining states blame the high state budgetary cost. While these states do have significantly higher expansion costs, they are also significantly more likely to have Republican Party control of the legislature and governor office. Statistical inquiry confirms that after controlling for costs, it is indeed political party control, particularly of the lower chamber of the state legislature that is the most important statistical determinant of state Medicaid expansion decisions.

Keywords:

• Medicaid expansion
• ACA
• ideology

JEL Classification:

• H72
• H75
• H77

Notes

¹ Ordered probit and logit models using an intermediate value for the four ‘maybe’ states produced identical results.

² Nebraska is omitted due to its nonpartisan unicameral legislature.

³ The results are robust to alternative measures of cost, such as including both the federal and state amounts as well as measuring the costs in dollars or as a per cent of the entire state budget.