The Affordable Care Act and the Diffusion of Policy Feedback: The Case of Medicaid Work Requirements

Abstract

Over the last five years, many states have sought to limit access to Medicaid by adopting restrictive policies. How can we reconcile this development with studies that imply that Medicaid should be insulated from policy backlash? The answer lies in understanding the policy feedback effects that accompanied Medicaid expansion and how these effects created electoral pressure that led to policy modification. We situate our expectations within a policy diffusion framework that accounts for variation in both the content and timing of policy adoptions across states. We develop and test several hypotheses using survey data and an original dataset on gubernatorial support for Medicaid work requirements. Our hypotheses are generally supported and provide a more nuanced understanding of the policy feedback effects following Medicaid expansion.