One of the most important public policy battles in America today is the Medicaid-expansion provision of the Affordable Care Act, which 20 states still refuse to exercise. As Carter Price, a mathematician at the RAND corporation tells Salon, “The states that are not expanding Medicaid are foregoing billions of dollars in federal spending and tens of thousands of jobs.”
A new working paper by political scientist Patrick Flavin finds that, “subjective well-being increased among low income citizens in states that expanded Medicaid eligibility compared to states that did not.” So, what determines whether a state expands Medicaid? A new study adds a twist to this important literature: they find that lobbying has a strong influence on whether a state expands Medicaid.
In a forthcoming paper in the American Journal of Public Health, political scientists Timothy Callaghan and Lawrence Jacobs find that while partisan control of government explains much of the variation in Medicaid adoption, it can’t explain all of it. Instead, they find, “reformers can take concrete steps to widen the reach of Medicaid expansion in states with Republicans in power. Well-organized public interest groups have succeeded in states where they deploy lobbyists.” Their model finds that when the number of of public interest lobbyists increases as a share of the state population, states are more likely to move closer towards fully expanding Medicaid. This effect remains even after extensive controls:
“Even amidst the potentially confounding effects of partisan polarization, economic affluence, the inertial dynamics within states, and the well-funded pressure from businesses and professionals, lobbyists for public interest groups still wielded influence.”
The problem is that such lobbyists are often overpowered: On average business and professional lobbyists outnumber public interest lobbyists four-fold. While there were 7,300 lobbyists working for business or professional health organizations, there were only 1,675 who worked for health advocacy organizations and 226 for unions in the health sector. But the important lesson is that when progressives mobilized, they can have impact. It’s an important lesson from a rather dispiriting literature.
Earlier this year I reviewed the research and showed that the core factor driving Medicaid expansion was not economics, but rather politics. And, while the work of other scholars, like Alexander Hertel-Fernandez, Theda Skocpol and Daniel Lynchfocused on divides within the business community, Callaghan and Jacobs show that it’s also important to focus on activism. Another factor at work is the donor class. As Inoted in a discussion of the work of Michael Barber, a political scientist at Brigham Young University, GOP donors are far more opposed to the Affordable Care Act than non-donors:
