Emma Sandoe

Emma Sandoe

Associate Director of Strategy and Planning, North Carolina Dept of Health Benefits
Adjunct Professor, Duke University

Dissertation Title:  "The Politics of Medicaid and Insurance Coverage Expansion: Voters, Interest Groups, and Policy-Making"

Health insurance coverage and politics are intertwined. This dissertation will examine how voters respond when there are changes to health care policies, why state legislatures and state executives act to address health care workforce shortages, and how interest groups utilize the political system to effectively pass policies.

Chapter 1 evaluates the effect of coverage expansion on voter participation. One of the recognized benefits of increased health coverage is that it leads to improved financial wellbeing for beneficiaries. With improved financial status individuals may be more likely to engage in activities that previously had access barriers. One potential barrier that health insurance may alleviate is the barrier to voting. This paper will address 1) whether improved health insurance coverage and availability of Medicaid creates the observed effects; 2) whether improved voting participation resulted following the expansions of health insurance coverage; and 3) whether there is a threshold at which coverage expansions no longer effect voting behavior. We examine two states, Massachusetts following the 2006 coverage expansions and Florida following the 2014 coverage expansions.

Chapter 2 examines the political conditions necessary for states to act to increase home care worker wages. Home care workers are among the largest and fastest growing segments of low-wage workers. In many states home care workers earn near hourly minimum wage. Medicaid is the primary payer for long-term care services and services provided in the home and community settings by home care workers. Medicaid’s large share of the home care market implies that policy made by a state Medicaid program could have a significant effect on home care worker wages in the private market. In recent years, state legislatures have taken actions to increase the wages for home care workers in the Medicaid. We examined 48 attempted wage increases and 34 successful wage increases from 2013-2018 to determine what political factors increase the likelihood that a state will increase home care worker wages. Union membership in the state, females in the legislature, and more professional legislatures were associated with increases to home care worker wages.

Chapter 3 evaluates the changing role of direct democracy in health policy using Medicaid expansion as a case study. From November 2017 through November 2018 four states voted to expand through ballot initiative and only one voted to expand Medicaid through the legislature. Why have states decided to use this method of policy making, instead of passing the law through the legislature and governor? Setting Medicaid eligibility through direct democracy represents a growing change in how health policy is made in states and how ballot initiatives are used to change health care programs. The four Medicaid expansions are representative of this shift in method of policy making and were a way to overcome legislative obstructions through the traditional policy processes in states. These ballot initiatives passed because Medicaid expansion is popular among voters, interest groups advocating for these changes were well organized and funded, and they utilized local and national organizations to influence voters.




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