This is a guest post by George Washington University political scientist Elizabeth Rigby.
As the health insurance exchanges open up for business, many are watching closely to assess the success or failure of the Affordable Care Act. Despite optimistic projections that 15 million additional Americans will get health insurance this year, the law’s real impact will depend on a complex—and tense—interplay between federal and state policymakers, as well as a whole host of private and non-profit service providers in the health industry. Already, many states, particularly Republican-controlled states, have resisted or refused to implement aspects of the ACA.
My research shows that this pattern is nothing new. For years, another key health program jointly administered by federal and state authorities—Medicaid—has been affected by which party happens to control state government. This is true for big decisions like eligibility limits as well as less visible administrative practices that make it easier or harder for people to enroll in Medicaid. When Republicans control the state government, it takes more information, documentation, and effort for citizens to enroll. Social scientists call this the “administrative burden”—that is, the burden placed on someone who wants to enroll in a program. To put it in more familiar terms, administrative burden is bureaucratic red tape.
To understand the administrative burden associated with Medicaid, Donald Moynihan, Pamela Herd, and I gathered data on the requirements to apply for Medicaid in each state. As reported in a new paper, we uncovered a great deal of variation across states — even before the Affordable Care Act was enacted. For example, as of 2010 the number of questions on a Medicaid application ranged from 49 in New Mexico to 248 in Michigan. Similarly, about a quarter of the states had interview or recertification requirements that make it time-consuming to enroll or re-enroll in Medicaid. This map compares the burden across states based on a measure combining all our indicators of administrative burden:
The wide variation is evident—from states with relatively low burdens, like Connecticut and Arkansas, to states with relatively high burdens, like Nevada and Nebraska.
What explains this variation? We found that the states with the most onerous application requirements were those with long histories of Republican Party dominance in the state government. Republican-dominated states had Medicaid applications that were longer and required more pieces of documentation. A seemingly-non-political administrative task — creating an application for Medicaid — has become heavily politicized.
Of course, when it comes to implementing the Affordable Care Act, the potential for states to create administrative burdens is subordinate to their willingness to participate in the ACA’s programs in the first place — such as the health insurance exchanges and the expansion of Medicaid. The decision by most conservative states to hand over operation of their state exchange to the federal government means that it will be the federal government, not state governments, determining the level of administrative burden.
And this presents a final irony, perhaps: by ceding control to the federal government, Republican governors and state legislatures actually have given up some of their own power — the power to determine administrative burden — when it comes to implementing Obamacare.