Health Policy Reform in the 50 States, 2011-2022
2022-08-18
Chapter 1 Introduction
1.1 Congress
The summer of 2017 was marked by the dramatic meltdown of Republican “repeal and replace” legislation in Congress. A major political development that played a part was the significant rise in public approval for the Affordable Care Act. Prior to 2017, numerous surveys (including the Kaiser Family Foundation tracking polls) have shown that nearly all elements within “Obamacare” have vast majorities in favor, at the same time as support for the law overall remained polarized. That changed with the introduction of concrete Republican legislation to overturn the ACA, when overall favorability climbed well into majoritarian terrain. Even Republican identifiers in surveys gave dismal ratings to the Republican leadership and its legislation. The disjuncture between national Republican attempts to overturn the Affordable Care Act and public support for it is striking, especially given older evidence of responsiveness in health policy spending (Soroka and Lim 2003; Wlezien 2004).
1.2 Public Opinion
When Americans are asked which party they trust to enact health care policy, they disproportionately say (in national samples) they trust the Democratic party.
Figure 1.1: Issue Ownership of Health Care
When the Affordable Care Act was passed, it was deeply polarized in public opinion. That has changed, with the ACA now (nationally) leading in support.
Figure 1.2: Affordable Care Act Approval
1.3 State Examples
1.3.1 The Latecomers: Medicaid expansion in Virginia and Montana
1.3.1.1 Virginia
Virginia Voters in November 2017 dealt a stunning blow to Republicans who controlled both chambers of the state legislature. The previous Republican-controlled legislature had been instrumental in blocking Medicaid expansion in the state despite a Democratic governor who strongly supported it, and statewide public opinion which also was significantly in favor. Yet Republicans retained a bare majority in the House of Delegates, and still controlled the State Senate. But individual Republicans including State Senators Frank Wagner and Emmet Hanger Jr., and Delegates Chris Peace and Terry Kilgore, changed their position on expansion and created a coalition with the Democratic minority to successfully pass Medicaid expansion.
What happened in Virginia? Why did legislators take the initial positions that they did, and why did some change their minds? Partisanship is obviously important, as the two parties staked out very different positions. But it is not nearly nuanced enough to explain what happened, as the Republican caucus internally divided enough for the legislation to pass. Another aspect to the story is ideology; there is a great deal of variation within the Virginia Republican party on policy preferences. According to my data on state legislative ideology, these four legislators are unusually moderate in their own party on a whole host of issues. Or perhaps it was public opinion on expansion that turned the tide, accentuated by an electoral message sent by voters in November. It could also have been district-specific factors like the fact that Kilgore’s district being one of the poorest in the state (and with 4,800 people likely eligible for gaining coverage as estimated by the AARP) and one experiencing a recent hospital closure, and therefore one that could gain the most from expansion. Finally, it could have been conservative and liberal pressure groups which were active in lobbying legislators. Theda Skocpol and Alexander Hertel-Fernandez classify Virginia as one of the highest on their right wing network scale, as ALEC, the State Policy Network, and Americans for Prosperity were extremely active and had thwarted expansion in 2014 (Hertel-Fernandez, Skocpol, and Lynch 2016). So was Virginia Organizing, a liberal interest group with a chapter in Kilgore’s district, that put a lot of pressure on him by placing letters to the editor in the local paper, holding a widely publicized district vigil, and meeting with Kilgore on numerous occasions to lobby for the bill. They were joined by business organizations like the Chamber of Commerce who disagreed with their conservative allies on expansion.
Figure 1.3: Medicaid Expansion in Virginia
1.3.1.3 Overall
The overall picture in the country in Figure 1.5 shows Medicaid expansion happened in a large majority of states as of December 2020. However, big holdouts like Texas and Florida continue under the pre-2010 system of extremely tight eligibility for Medicaid.
Figure 1.5: Medicaid Expansion in the States as of December 2020
1.3.2 The Public Option in Washington State
President Biden was elected after having promised a public option as a prominent part of his 2020 electoral campaign. As of this writing, the public option appears to have been put on the backburner, behind the push for stimulus, infrastructure, and family omnibus spending bills. The president has instead used executive orders to, amongst other things, reopen the signups for exchange marketplaces.
Legislative action on the public option instead actually exists in Washington State. There, Eileen Cody wrote a bill that was eventually passed in the legislature and signed by Governor Inslee.
Figure 1.6: The Public Option in Washington State. Eileen Cody, bill author, and signing ceremony
1.3.3 Single Payer in California
In California, a single payer bill (SB 562) that would have utilized a section 1332 innovation waiver–pushed by progressive Democrats and the state nurses union–was adopted by the California State Senate in June 2017. Yet shortly thereafter, the Democratic Speaker of the Assembly decided to table the legislation, to the fury of its supporters. The state is marked by unified Democratic control of the legislature and the governorship, so a simple partisan analysis of why SB 562 failed would fail to provide insight. The internal fight in the Democratic party to push a state response to Trump administration policies is the centerpiece of trying to understand the future of Affordable Care Act in the nation’s largest state. That fight is still ongoing, as 16 bills have just been introduced by Democrats in July 2018, including another attempt at single payer.
The Virginia and California stories are microcosms of what is happening across the country’s over 7,000 individual state legislative districts. While state capitols are the site of much of the action, so too is the district-by-district contest to push for health policy changes. Similarly, while interparty dynamics between Republicans and Democrats are important, yet many of the policy reforms are being hashed out in the context of intraparty debates and single-party states. Yet we know very little about how policy is developed at the district and intraparty levels. This project would aim to change that.
1.4 Downs syndrome coverage in Montana
- H 318 requires insurance to cover the diagnosis and treatment of minors with Down’s syndrome
- 104 sessions/year with speech pathologist, and 52 sessions/year with physical therapist & occupational therapist
- Sponsored by Ellie Hill (D), most liberal 10% of chamber, 27% of Ds
- Senate R majority gets rolled, House R majority divided
- 76-23 final vote in House (41-0 D, 35-23 R)
- 56-40 final vote in Senate (40-0 D, 16-40 R)
- Signed by Governor Bullock (D)
Figure 1.7: Montana Representative Ellie Hill
1.5 Surprising Billing Regulation
Balance bills are colloquially called “surprise bills.” They generally occur when insured individuals receive emergency care at an out-of-network facility or from an out-of-network provider, or when they receive elective nonemergency care at an in-network facility but is inadvertently treated by an out-of-network health care provider. Being out-of-network is crucial since insurers typically refuse to pay a large portion of these bills. In turn, then, the provider or facility might bill the insured individual, who is surprised to find a huge bill due despite their insurance coverage.
While surprise billing restrictions were enacted by Congressin December 2020 – and only comes into effect in 2022– states had for years enacted these protections. Even Texas–whose legislature only meets for six months every two years–passed this bill before Congress finally moved.
Figure 1.8: Balance Billing State Laws, November 2020
1.5.1 Autism coverage mandates
Two decades ago, insurance companies only covered the extensive therapy required by autism-spectrum patients idiosyncratically. That changed over the 2000s, and by 2019 the final state, Tennessee, passed the 50th autism insurance mandate in the country.
Figure 1.9: Autism coverage mandates in the states
1.6 The bigger picture
How well do the unsung workhorses of American representative democracy–its thousands of state legislators–represent their constituents on the most vital issues of the day? Are the decisions they make in the statehouse reflective of the wishes and needs of their constituents, or do other influences–their own preferences, those of their party, and those of particularized interests–hold more sway? This question is particularly important in understanding the thoroughly politicized domain of health care. Policy made in statehouses affects the lives of hundreds of millions of Americans, yet little is known about how that representational relationship actually works. The project proposed here will advance our understanding of these relationships, specifically by the use and amalgamation of new sources of data that would have been impossible only a few years ago.
I identify five relevant influences on state legislators in their bill introductions, sponsorship, committee action, and roll call voting behavior. Do more liberal views by district constituents on the Affordable Care Act predict more liberal voting patterns by their representatives in the statehouse? Do objective measures of need – specifically measures of poverty and health insurance coverage – also predict such patterns? Or are such variables overridden by legislators’ own ideological preferences or partisanship? What role do particularized interests–both of the ideological and economic interest varieties–play in influencing legislators?
Whether elected representatives’ behavior is congruent with constituent opinion and policy needs is a fundamental inquiry in a representative democracy, and has been a major touchstone in the research on American politics. However, earlier work concentrates on representation at the federal level. When states are studied, it is almost entirely in statewide terms. Finally, representation is understood in general ideological terms rather than in specific policy areas like health. In short, we know very little what happens in the states, in terms of specific policies, and at the district level because of measurement difficulties. This project would address those issues by the use of new data and new techniques. Bringing these together would allow us to understand how and when viable coalitions to implement (and delay) Affordable Care Act implementation in the states.
1.6.1 Early Findings from this study
- Health reform in the states is moving leftward in legislatures. Why?
- Democratic majority chambers
- Disproportionate production of health care legislation
- Agenda control is strong
- Party is united
- Liberal proposals dominate and succeed relative to moderate and conservative ones
- Republicans majority chambers - Substantial failures of agenda control- Substantial failures of party discipline in voting - Moderate bills do very well, liberal bills often succeed
1.6.2 Why study states?
The explicit federalist design of the Constitution, as well the specific institutional history and context of American health policy making, means that states have a major role to play in how the Affordable Care Act unfolds in the post-2016 political environment. Indeed, placing states at the center of ACA implementation was meant to ameliorate political opposition to the ACA, both within the Democratic party (to appease moderates like Nebraska Senator Nelson), and as a way to reach out to Republicans.
In short, states are where the policymaking action is, as long as Congress remains mostly gridlocked when it comes to health. The National Conference of State Legislatures counts 111 enacted state bills in 33 states since January 2017 alone that directly address specific choices states have under the ACA.1 Alaska, Kentucky, Maine, Texas, New Hampshire, and Oklahoma all enacted legislation authorizing applications for section 1332 innovation waivers (sometimes called ``superwaivers’’). These are nearly all Republican-controlled states, and these waivers can be expected to undermine the ACA at the state level, especially given the signaled support from the Trump Administration to grant these waivers. Other, typically Democratic, states like California, Hawaii, Nevada, and Minnesota has passed laws which augment the ACA’s provisions for their populations. Reinsurance programs have been approved via 1332 waivers in Minnesota, Alaska, Oregon, and New Jersey. In New Jersey, too, a newly elected Democratic governor signed a state health insurance mandate bill to counter the national law eliminating the mandate (so too did a Republican governor in Vermont). All in all these are themselves only a portion of all health insurance reforms that indirectly touch on the ACA: 639 laws in all 50 states in 2017-2018 alone, and more than 1,400 laws passed since 2015.
The important political context is the partisan division of state control. After the 2016 and 2017 elections, Republicans now have unified control of 32 state legislatures (25 states with ``trifectas’’ of unified control of both chambers and the governorship). Yet Democrats, too, control state legislatures in 14 states (8 states with trifectas) – far fewer, but including large states like California and New York. The Blue Wave propelling Democrats to victories in the 2018 midterm elections are also likely to be mirrored at the state level, since research shows these to be highly correlated (Rogers 2016).
Now that the congressional battle is over, and state policies challenging (and augmenting) the ACA are accelerating, the question naturally arises whether state policy, too, will override public opinion. This is crucial because the ACA gives tremendous discretion to states to modify policy implementation on the ground, and the presidency gets nearly unlimited scope to approve these modifications, especially waivers. Will, for example, section 1332 waivers undermining (and augmenting) the ACA pass despite public approval for the ACA as a whole?
Another puzzle that needs unraveling is the disjuncture between health policy lawmaking at the state versus national levels. Health policy is often severely gridlocked at the national level. Even beyond the gridlock induced by multiple veto players (Krehbiel 1998), health policy in particular is far more gridlocked than other policy types (Volden and Wiseman 2011). Yet at the state level, this is far less true, and this difference is not new. Major health reforms have been implemented in many states that have not moved at all at the national level (Gray, Lowery, and Benz 2013).
In terms of state health policy, there is a tremendous amount of lawmaking going on, even in controversial areas. Since 2015, several hundred health reforms laws have been enacted with over 1,000 final passage roll call votes. Strong supermajorities of Democratic support for the reforms is not surprising. Yet far from unanimity in opposition, Republicans at the state level have voted for these reforms at strikingly high rates, at nearly 50%. Even the most controversial reforms attract significant Republican support, such as Medicaid expansion (20% support) and state health insurance exchanges (28%). These Republican votes have often provided pivotal in the passage of these reforms. The evidence for Republican support for a much wider array of health policy reforms is quite striking. Figure @ref(topic.splits) shows the split of the parties on final passage votes for 15 of the most common health policy reforms. Democrats vote at high rates, but Republicans do sometimes, too. Bipartisan coalitions frequently roll majority parties in the states at rates unheard of in Congress.
A broader preliminary look at far more health policies (see below) shows that the Republican party is deeply divided in its votes for health reform measures (see Figures x-y). On average, the party votes in favor of such measures at around 50%, a figure that masks incredible variation at the state, topic, and ideological level. Understanding when and why Republican votes on progressive policy reforms can be forthcoming is crucial to mapping out the future of ACA implementation in the states. In the fight to expand Medicaid, knowing which concessions in which states need to be made can help in constructing progressive policy coalitions.
At the same time, while the Democratic party has been much more homogenous in its support for standard progressive health reforms, bleeding edge innovations like single-payer have been much more internally divisive. Especially in Democratic-dominated states like California, attention to the intraparty debate is much more insightful than examining the state interparty divide in a place where the Republican party is almost totally irrelevant.
1.6.3 Why study districts?
Since lawmaking involves the construction of a series of majoritarian and supermajoritarian coalitions in the state legislatures, understanding legislator-level decisions in that process is crucial. Legislators choose on their own whether to sponsor a bill, whether to propose an amendment, and how to vote on an endless stream of roll calls. They make these decisions under the eye of legislative party leaders and the governor, not to mention the news media, donors, interest groups, and their constituency, but the decision is an individual one.
This is well understood in studies of Congress, where individual legislator decisions contraposed with district level factors is fairly common. But for states, macro-representation dominates. Aggregate outcomes across states and times are compared with dynamic state-level factors. Since policy is the output of a complex set of state level institutions, this is an entirely appropriate level of inquiry. But it does not supplant the need to understand individual legislator behavior, particularly in understanding when and where coalitions form to pass particular policies.
A major reason for the imbalance in favor of studies of macrorepresentation is the incredible difficulties of measurement in district or legislator-level microrepresentation (as contrasted with Congress). Yet a methodological and measurement revolution has generated groundbreaking new measures and techniques which is changing all of that. Whereas measures of simple partisanship were all we had only a few years ago, now we have legislator-level ideal point measures for the past two to three decades (Shor and McCarty 2011; Shor 2020). Whereas we had only district-level demographic information as proxies for opinion, now we have district-level measures of general ideology (Tausanovitch and Warshaw 2013), and techniques to get district-level opinion on specific policies [Warshaw and Rodden (2012); Shor:2018]. District-level measures of interests were impossible before, while now we can get donor-level data aggregated to the district level (Bonica 2013, 2017; Bonica et al. 2017). Bill and roll call information, too, was locked in legislator journals and other inaccessible sources. Changes by states themselves and open government initiatives like OpenStates has made these now fully searchable and accessible electronically.
References
Taken from the NCSL Health Innovations Database, July 2018. See http://www.ncsl.org/research/health/health-innovations-database.aspx↩︎