State Politics And The Uneven Fate Of Medicaid Expansion.

Under the Affordable Care Act (ACA), state governments play a central role in deciding whether millions of low-income Americans have access to Medicaid. During the early years of ACA implementation, conservative opposition stalled the expansion of eligibility for Medicaid in many Republican-controlled states, even in the face of strong fiscal incentives. Can any forces overcome this partisan divide? In this article we consider the role of several key mechanisms that have affected Medicaid expansion over the past decade, including electoral competition, ballot-box initiatives, interest-group coalitions, and entrepreneurial administrators. While each mechanism has helped place Medicaid expansion on the agenda, they have done so unevenly. In Republican-controlled states where electoral competition is weak and ballot initiatives are unavailable, Medicaid expansion remains unlikely. Even when expansion is successful at the ballot box, however, state legislatures and governors have been able to delay or reverse voter-led initiatives. Moreover, the highly salient and partisan nature of Medicaid expansion has made it difficult for interest-group coalitions and progressive administrators to play a leading role in policy change. The future of Medicaid expansion, as well as other significant portions of the ACA, will continue to depend on the character of representative democracy in the states.

The New Politics of US Health Care Prices: Institutional Reconfiguration and the Emergence of All-Payer Claims Databases.

Prices are a significant driver of health care cost in the United States. Existing research on the politics of health system reform has emphasized the limited nature of policy entrepreneurs' efforts at solving the problem of rising prices through direct regulation at the state level. Yet this literature fails to account for how change agents in the states gradually reconfigured the politics of prices, forging new, transparency-based policy instruments called all-payer claims databases (APCDs), which are designed to empower consumers, purchasers, and states to make informed market and policy choices. Drawing on pragmatist institutional theory, this article shows how APCDs emerged as the dominant model for reforming health care prices. While APCD advocates faced significant institutional barriers to policy change, we show how they reconfigured existing ideas, tactical repertoires, and legal-technical infrastructures to develop a politically and technologically robust reform. Our analysis has important implications for theories of how change agents overcome structural barriers to health reform.

Boutique to Booming: Medicare Managed Care and the Private Path to Policy Change.

In 2014, Medicare Advantage (MA) enrollment surpassed 30 percent of eligible beneficiaries. Twenty-five years earlier, enrollment hovered at just 3 percent. The expansion of private Medicare plans presents a puzzling instance of policy change within Medicare-a program long held to be a quintessential case of policy stasis. This article investigates the policy features that made Medicare susceptible to this dramatic policy shift, as well as the processes by which the initial policy change remade the politics of Medicare and solidified the MA program. The first enrollment surge occurred in the absence of a proximate legislative or administrative change. Instead, increased spending and expanded benefits were the result of the interaction of new market dynamics with an existing legislative framework-demonstrating an expansionary form of policy drift. The 1982 Tax Equity and Fiscal Responsibility Act created a policy space that gave the new and lightly controlled managed care industry considerable operational discretion. As the interests of the government's private partners changed in response to new market dynamics, a change occurred in the output and performance of the Medicare managed care program. As enrollment and spending increased, Medicare's politics were remade by the political empowerment of the managed care industry and the creation of a new subconstituency of beneficiaries.