Dissertations and Theses

Date of Degree

6-2-2020

Document Type

Dissertation

Degree Name

Doctor of Public Health (DPH)

Department

Health Policy and Management

Advisor(s)

ELIZABETH EASTWOOD, PhD

Committee Members

ELIZABETH EASTWOOD, PhD

P. CHRISTOPHER PALMEDO, PhD, MBA

ALICE SARDELL, PhD

Subject Categories

Public Health

Keywords

Medicaid, Affordable Care Act, Public Policy, Qualitative Content Analysis, Social contruction, deservedness

Abstract

When the U.S Supreme Court in 2012 ruled that the federal government could not withhold Medicaid funding from states that did not expand Medicaid to low income, non-disabled adults under the Affordable Care Act (ACA), Medicaid expansion became a state option. By the end of 2015, nineteen states had not expanded Medicaid, excluding about 2.5 million individuals from affordable health coverage and access to care. Prior research explored the reasons certain states expanded or did not expand Medicaid, but state decisions did not always result in one of these binary outcomes. There were four policy responses to the ACA’s Medicaid expansion: accepted expansion; accepted expansion with conditions; refused expansion but designed alternate expansion for a subset of the intended population; and refused expansion. Equally important, previous studies did not examine the political discourse leading up to a state’s Medicaid policy outcome. Incorporating the social construction of target populations approach, I conducted a qualitative content analysis of the political discourse in six states representing the four responses to: identify how government officials and non-governmental organizations constructed deservedness among Medicaid target populations; determine the extent to which the constructions of deservedness reflected, reinforced, or contested the four Medicaid eligibility designs; and analyze the extent to which Medicaid eligibility design created tiers of deservedness among different target populations. In addition to the social construction of target populations, the most common themes in the discourse for both supporters and opponents of expansion were the: economy, budget and financial sustainability; coverage and care; and state autonomy, capacity and innovation. Besides the discourse, other conditions connected to the Medicaid decision were political party and role of the Governor and a state’s policy legacy of prior Medicaid expansions.

Available for download on Wednesday, May 12, 2021

Included in

Public Health Commons

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