THE POLITICS OF EXPANDING MEDICAID IN REPUBLICAN-LED STATES: LESSONS FROM ARIZONA, INDIANA, AND TENNESSEE

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. 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.Doctor of Public Healt