Rachel Garfield

Rachel Garfield

Vice President and Co-Director, Program on Medicaid and the Uninsured, Kaiser Family Foundation

Dissertation Title:  "Political and Fiscal Forces in State Health Policy"

States play a crucial role in financing, administering, and delivering health services in the United States health care system. In recent years, state health policy has been the subject of debate, as states struggled to meet rising costs and growing need, sought increased flexibility in decision-making, and redesigned systems to keep abreast of changes in service delivery. This dissertation informs these debates by studying how state health spending, policy outcomes, and decision-making processes interact with state-level politics, economic conditions, and institutional structures.

The first paper uses unique panel data of state spending, politics, and demographics to analyze how state Medicaid spending responds to state fiscal crises and political factors. I find that, after controlling for need, state Medicaid spending changes are not related to state fiscal downturns, though overall state spending declines in these periods. Liberal ideology is a significant, positive predictor of annual changes in state Medicaid spending, while party control and the strength of health interest groups are not associated with short-term changes in state spending. The results suggest that state Medicaid spending follows a unique budget pattern within states. Since the passage of the State Children’s Health Insurance Program (SCHIP) in 1997, all states have expanded children’s eligibility for publicly-financed health coverage.

The second paper investigates whether and how state economic conditions, politics, and need predict state choices in such coverage. It finds that pre-1997 eligibility was driven largely by political ideology and legislative control, as liberal states and states with Democratic legislatures had more generous eligibility criteria. Post-1997 changes in eligibility responded to the party of the governor, rather than legislature, and depended on state poverty levels but not annual budget fluctuations. Complex dynamics in state mental health systems create tensions in state priority setting for mental health policy.

The final paper uses qualitative evidence gathered through semi-structured interviews with state policymakers, advocates, and providers in four states to understand how policy priorities are set in state mental health policy. It finds that a combination of leadership, reliance on structured relationships, and reaction to outside actors or events characterizes priority setting in state mental health policy.

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