Humanities
PSC 309 UCF Medicaid Expansion and the Political Fate of the Governors Paper

University of Central Florida

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I’m studying for my Political Science class and don’t understand how to answer this. Can you help me study?

You will participate in a series of “research updates” throughout the semester. We will be periodically reading the most up-to-date research within state politics, and you must review the research question, methods, and findings in your own words, along with providing original insights of your own. You will follow the CREATE method to help you do this.

All papers must be three full pages with 12 point, times new roman font and one inch margins (double-spaced). You must attach a memo showing your CREATE notes. This does not count towards your overall page count.

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Research Updates You will participate in a series of “research updates” throughout the semester. We will be periodically reading the most up-to-date research within state politics, and you must review the research question, methods, and findings in your own words, along with providing original insights of your own. You will follow the CREATE method to help you do this. 1 Consider Read Elucidate the hypothesis Analyze and interpret the data Think of the next Experiment Your paper must begin with your evaluation of the paper, where you include a statement that captures your original thoughts about it. “This is a good paper” is not acceptable. “This paper by Hanson (2020) is a positive development for our understanding of state legislative committee systems because of its original and thorough data collection effort” is acceptable. Throughout the rest of the paper, you should back up your statement by including specific evidence from the article, in addition to providing an overview of the paper and its contribution to the literature. Be sure to include all components of the CREATE model within your paper. All papers must be three full pages with 12 point, times new roman font and one inch margins (double-spaced). You must attach a memo showing your CREATE notes. This does not count towards your overall page count. You will complete three research updates worth 15% of your final grade. Notes on mechanics: Do not include block quotes. I know they fill up the pages, but ultimately they’re a lazy way of summarizing a journal article. Do not tell me about Bayesian Information Criterion, pooled event history analysis, negative binomial regressions, or any other methods that I know you don’t use or know about. I want you to tell me, in accessible terms, how the results speak to the authors’ expectations. Include page numbers at the top of each page. bs_bs_banner Policy Studies Journal, Vol. 47, No. 2, 2019 Medicaid Expansion and the Political Fate of the Governors Who Support It Richard C. Fording and Dana J. Patton We provide evidence regarding potential policy feedback effects of healthcare reform by estimating the effect of Medicaid expansion on public support for the state actor most closely associated with responsibility for the expansion decision—the governor. The discretion granted to state governments concerning Medicaid expansion has created the potential for significant variation in mass feedback effects across the states. We are particularly interested in how these effects are influenced by the emerging racial polarization over healthcare policy, and how this may lead to different types of feedback effects that align with partisan, ideological, and racial cleavages. We estimate the impact of Medicaid expansion on gubernatorial approval, utilizing five waves of the Cooperative Congressional Election Study (2008–16). We find that on average, expansion led to a modest, yet statistically significant increase in gubernatorial approval. However, there is important variation both within and across states in the effect of expansion. Specifically, we find that governors were more likely to be rewarded for expansion by those who supported President Obama, and those who resided in states where the Medicaid recipient population is more likely to be white. 州长是与扩大联邦医疗补助规模这一决定在责任上关联最大的州行为者,我们通过估算医疗 补助扩展会在多大程度上影响公众对州长的支持,为“医疗改革可以带来潜在的政策反馈效应”这 一论断提供了证据。州政府在扩展医疗补助上拥有自由裁量权,这使得各州在公众反馈效应上出现 差异。本文尤为关注反馈效如何被医疗政策中新兴的种族两极化观点所影响,以及这种影响将如 何引起与党派、意识形态和种族分裂观点相对应的不同类别的反馈效应。我们使用合作国会选举 研究(Cooperative Congressional Election Study)在2008到2016年间五次调查的结果,估算了医疗 补助扩展对州长获批连任的影响。我们发现,平均而言,医疗补助扩展带来了州长获得批准的小幅 但统计意义上显著的增长,但扩展带来的这种影响在各州内部和各州之间有显著差异。具体来说, 我们发现那些支持奥巴马总统的人以及那些居住在联邦医疗补助受助人口以白人为主的州的人更 有可能支持他们的州长,使得州长可以获得推行医疗补助扩展的“奖励”。 Despite significant political opposition in Congress and predictions that it would plunge the country into socialism, the Patient Protection and Affordable Care Act of 2010 (ACA, aka “Obamacare”) was passed without a single Republican voting for the bill. Although it did not provide universal coverage, the enactment of the ACA was the most significant reform of healthcare policy in the United States since 1965. For this reason, as well as the contentious history of the healthcare debate in the United States, scholars have employed a variety of theoretical approaches to better 274 doi: 10.1111/psj.12311 © 2019 Policy Studies Organization Fording and Patton: Medicaid Expansion and the Political Fate of the Governors Who Support It275 understand how politics affected the design (Rigby, Clark, & Pelika, 2014), adoption (Brown, 2011; Daschle & Nather, 2010; Hacker, 2011; Jacobs & Skocpol, 2012), and ongoing implementation (Barrilleaux & Rainey, 2014; Jones, Bradley, & Oberlander, 2014) of the policy. A growing body of literature has examined the politics of healthcare reform through the lens of policy feedback theory. Broadly, policy feedback refers to the effect that a policy has on politics, as well as future policy development (Béland, 2010; Pierson, 1993; Skocpol, 1992). The early work on policy feedback theory focused almost exclusively on policies that guaranteed benefits to a targeted group (e.g., veterans, senior citizens). These benefits created a sense of entitlement that resulted in supportive constituencies and ultimately, policy entrenchment (Mettler, 2002; Oberlander & Weaver, 2015; Weaver, 1986). As noted by Oberlander and Weaver (2015), positive policy feedbacks are “self-reinforcing” for these popular entitlement programs. However, they argue that an important type of policy feedback has been understudied—policy feedback that is “self-undermining” or “mixed” (see also Campbell, 2011, and Patashnik & Zelizer, 2013). More recent research on policy feedback theory has thus sought to identify the specific conditions which determine whether feedback effects are self-reinforcing, self-undermining, or some mix of the two (Béland, 2010). A number of recent studies have utilized a policy feedback framework to understand the feedback effects of healthcare reform. Several of these studies have focused on the impact of Obamacare on potential self-reinforcing feedback effects operating through the political attitudes and behavior of program targets (Campbell, 2011; Chattopadhyay, 2017; Haselswerdt, 2017; Hopkins & Parish, 2017; Lerman & McCabe, 2017). Despite differences in data sources and the operationalization of the target population, all but one of these studies (Chattopadhyay, 2017) finds evidence of positive feedback effects. A handful of studies have examined the potential “mass feedback” effects of the ACA. Rather than focusing solely on elites or the targets of the policy, policy feedback studies in this vein examine the effects of a policy on “the preferences, beliefs and behaviors of broader mass publics” (Soss & Schram, 2007, p. 111). As we detail below, the findings from this research suggest that positive feedback effects have been “minimal” and mitigated by partisanship (Sances & Clinton, 2017) and racial attitudes, which were primed after passage of “Obamacare” due to the fact that its chief advocate—Barack Obama—was black (Grogan & Park, 2017; Henderson & Hillygus, 2011; Tesler, 2012, 2016). The possibility of self-undermining feedback effects for Medicaid expansion is further enhanced by the efforts of conservatives to frame expansion as an increase in “welfare” for the “undeserving poor” (Schneider & Ingram, 1993). In this paper, we extend this literature on the policy feedback effects of the ACA by estimating the effect of Medicaid expansion on public support for the state actor most closely associated with the responsibility for the expansion decision—the governor (Béland, Rocco, & Waddan, 2016). To date, research on the policy feedback effects of the ACA has generally been limited to the effects of reform on public support for the policy (Chattopadhyay, 2017; Hopkins & Parish, 2017; Lerman 276 Policy Studies Journal, 47:2 & McCabe, 2017; Stances & Clinton, 2017). While this connection between policy change and public opinion represents a central assumption of policy feedback theory, what makes the policy feedback framework so valuable to policy theorists is the additional assumption that these political effects will have important implications for future policy development (Béland, 2010; Pierson, 1993). Our research extends the literature on the policy feedback effects of healthcare reform by examining one of the most important mechanisms that connects change in public support for healthcare reform to future policy development—a concept we refer to as evaluative feedback (Gingrich & Watson, 2016). Evaluative feedback effects refer to changes in public support for the political elites deemed responsible for the initial reform. For evaluative feedback effects to occur, we must assume that citizens come to some degree of consensus regarding the political actor(s) responsible for the policy (regardless of whether their attribution of responsibility is accurate or not). When this happens, policy feedback effects on mass attitudes can have significant political consequences, as the populations affected by the policy will presumably direct their political punishment or reward at a specific political target (Weaver, 1986). This may affect the future of the initial policy in one of the two ways. To the extent that political elites are rewarded for the initial policy, this should lead to what policy feedback theorists refer to as “lock-in” effects—policy stability and perhaps even expansion of the initial policy. Alternatively, when political elites are punished for their role in the passage of the initial policy, this should lead to policy retrenchment, either through the efforts of incumbents to win back public support, or through elite replacement resulting from an electoral backlash. Many studies have examined the negative feedback effects of healthcare reform at the national level, where passage of the ACA has been found to have contributed to the rise of the Tea Party movement and the 2010 midterm backlash (Abramowitz, 2012; Tesler, 2012; Williamson, Skocpol, & Coggin, 2011). However, there is good reason to believe that important feedback effects have also been experienced at the state level, and that the target of the voter reward and punishment has been the governor. According to the original ACA legislation passed in 2010, governors were to play a relatively minor role in implementation. But as a result of the Supreme Court’s ruling in National Federation of Independent Business v. Sebelius in 2012, state policymakers were effectively granted the discretion to decide whether or not to expand Medicaid in their state. Governors and state legislators across the country suddenly became central actors in the implementation of Obamacare, with governors taking center stage (Béland et al., 2016). This discretion granted to state governments has not only created considerable variation in the content and impact of healthcare reforms, but it has also created the potential for significant variation in policy feedback effects across the states. We are particularly interested in how these effects were influenced by political polarization over healthcare policy in the United States, and how this may have led to different types of feedback effects that align with partisan, ideological, and racial cleavages (Tesler, 2012, 2016). We investigate this possibility by examining how the effects of Medicaid expansion on gubernatorial support varied across different subgroups Fording and Patton: Medicaid Expansion and the Political Fate of the Governors Who Support It277 defined by party and ideological identification, support for President Obama, and the state racial context. We test our hypotheses by estimating the impact of Medicaid expansion on gubernatorial approval, utilizing five waves of the Cooperative Congressional Election Study (CCES) that were administered in each federal election from 2008 to 2016. We find that on average, expansion led to a modest, yet statistically significant increase in gubernatorial approval. However, we find that there is important variation both within and across states in the effect of expansion. Specifically, we find that governors were more likely to be rewarded for expansion by those who supported President Obama, and those who resided in states where the black share of the Medicaid population was relatively small. In the final section of the paper, we discuss the implications of our findings for theories of policy feedback, as well as their relevance to understanding current efforts to reform Medicaid through the adoption of work requirements, as well as the future of healthcare reform. Theorizing the Link Between Medicaid Expansion and Gubernatorial Approval The first question to grapple with is whether we should expect Medicaid expansion to have any effect at all on gubernatorial approval. As Soss and Schram (2007) have shown, even a major policy change may not be visible or proximate enough to have a significant effect on mass attitudes. There are at least two possible reasons why we might expect Medicaid expansion to have a negligible effect on support for the governor. First, it is well known that citizens pay less attention to state politics than national politics due to higher information costs (Kelleher & Wolak, 2007). Therefore, many citizens may be unaware of their state’s expansion status (Béland et al., 2016; Stances & Clinton, 2017). Second, even if voters are aware of Medicaid expansion, it is just one of many possible issues that voters might take into consideration when formulating their opinion about their governor’s performance. In other words, Medicaid expansion may not have been salient enough to affect approval. While this is certainly plausible, survey data find that in recent years voters have regularly cited healthcare as an important policy problem. In the years immediately preceding and following the passage of the ACA, roughly a quarter of Americans believed that healthcare was “the most important problem facing the U.S.” (Gallup, 2017). In the years since Obamacare passed, the salience of healthcare has fluctuated, but it has consistently ranked among the top “problems” facing the country. Thus, it is not surprising that healthcare continues to be on the minds of voters when casting their ballots. In the 2016 presidential election, the Kaiser Family Foundation reported that 68 percent of the voters cited healthcare as a “major” factor in their voting decision (Kaiser Family Foundation, 2016). Thus, there is good reason to suspect that as one of the central components of the ACA, Medicaid expansion has been sufficiently salient to impact voter evaluations. We also believe that the most likely state-level political target of voters’ attribution of responsibility for Medicaid expansion has been the governor. Many studies find that as the chief executive, voters “look to governors to lead their states, credit 278 Policy Studies Journal, 47:2 them with any successes and hold them accountable for most failures” (Kousser & Phillips, 2012, p. 1). Research has shown that governors are held accountable for general goals, such as economic development and economic performance (Atkeson & Partin, 1995; Cohen & King, 2004), as well as major policy innovations such as welfare reform (Haskins, 2007; Katz, 2001) and education reform (Gittell & McKenna, 1999; Perna & Finney, 2014). We expect this to be just as true for the decision to expand Medicaid, which represents one of the most salient policy decisions made at the state level in recent years. In some states, governors utilized executive power to expand Medicaid and therefore their responsibility for expansion is clear. However, in most states, expansion required legislative action. Yet, even in these states the governor was the most visible political actor in the expansion process, and thus most likely to be deemed responsible. Governors’ positions regarding expansion were regularly highlighted in the news media, regardless of whether the legislature played a role in expansion and whether or not the governor supported expansion. For example, following the announcement by the Supreme Court that states could choose not to expand Medicaid, Governor Rick Perry announced that Texas would choose not to do so (Béland et al., 2016, p. 58). Numerous other governors followed suit in 2012, such as Rick Scott of Florida, Mary Fallin of Oklahoma, and Robert Bentley of Alabama. When states did choose to expand, national and state newspaper headlines often associated the incumbent governor with the decision.1 Indeed, we can find no instance in an expansion state where the presiding governor did not make their support for expansion well known. And in the vast majority of expansion states, governors were vocal supporters of expansion. Given the salience of governors in expansion decisions, we therefore focus our attention on the feedback effects of Medicaid expansion on gubernatorial approval ratings. Yet, exactly how these feedback effects might work is much less clear. As we detail below, the net feedback effects of Medicaid expansion may be positive or negative and are likely dependent on the state’s political context. Below, we theorize the aggregate feedback response as a combination of two types of feedback effects— positive, self-reinforcing feedback effects from policy targets, and a combination of positive and negative mass feedback effects originating from nontargets. Policy Beneficiaries and Positive Feedback Policy feedback scholars have most often studied feedback effects among policy beneficiaries. In the case of Medicaid expansion, perhaps the most obvious source of potential positive feedback is from low-income voters who were either already enrolled in Medicaid or became eligible for Medicaid due to expansion. Just as Social Security mobilized the elderly to become a potent political force to protect Social Security (Campbell, 2003), the growth in the Medicaid rolls caused by expansion of the target population may have led to positive feedback effects among policy beneficiaries in expansion states. Studies of feedback effects of Medicaid expansion have generally supported this proposition. For example, Campbell (2011) examined Fording and Patton: Medicaid Expansion and the Political Fate of the Governors Who Support It279 how the policy design of different components of the ACA affected beneficiary attitudes toward government. She found that policy design affected the preferences and mobilization of policy constituents, which subsequently fed back into the political environment. Haselswerdt (2017) studied the effects of expansion on political participation in the 2012 and 2014 elections. He found that expansion resulted in a surge in political participation in both elections and that this was at least partly due to an increase in turnout among newly enrolled Medicaid recipients. In a more direct test of feedback ...
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Running Head: RESEARCH UPDATE

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Research Update:
Medicaid Expansion and the Political Fate of the Governors Who Support It
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RESEARCH UPDATE

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Medicaid Expansion and the Political Fate of the Governors Who Support It
Expansion of Medicaid is one of the concerns that the Affordable Care Act of 2010 called
for from the states, but the court ruled that state officials had the power to decide on whether
they should expand it or not. 37 states with their governors from either democratic or republican
parties expanded their Medicaid to respond to the ACA 2010 requirement. The study is
important as it looks into state politics, and how partisan polarization affects the direction of
policies with regards to the addition of the work requirement clause in the Medicaid expansion
plan. Fording, & Patton (2019) looks into the support that this state government obtained from
the citizens and whether the governor called for the addition of the work required to the
expansion plan. The study investigates 37 states that expanded their Medicaid plans, with the
consideration of factors such as their Obama approval rating; whether they were racially
homogeneous or heterogeneous states; and whether they have a democratic or republican
governor. This information was related to whether the states supported the addition of the work
requirement in their Medicaid expansion plan. Obama’s administration did not support the
addition of work required to the Medicaid expansion plans at the state levels.
The study suggests that a president’s approval rating affects the policy direction, with
most states that show high president’s approval rating following the president’s
recommendations on state policies. 9 states that had expanded their Medicaid had a high Obama
approval rating. Only three of them had a republican governor, wi...

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