Hyein Ko

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Haofeng Ma

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Tracee Saunders

Dissertation Title: "Inaccessible by Design? Medicaid and the Politics of Administrative Burden"

Dissertation Abstract:

In my dissertation, I explore the interactive effects of state and local context, policy design, and administrative burden on policy take-up. Existing literature examines these individually, while I look at their combined effects. I demonstrate there is wide variation in how states design their Medicaid policies and the administrative burdens for enrolling. Since policy design and administrative burdens are not necessarily both dictated by state legislatures, they may not be as congruent as one would expect. If a state has a generous Medicaid policy (e.g. they offer more benefits than federally required and have expanded under the ACA), one may expect them to have relatively high take-up. However, if that generous policy is paired with high administrative burden, take-up may actually be low. On the flipside, there may be high take-up in a historically conservative state with restrictive policy design yet a simple application process and easily navigable and state Medicaid website. I argue state and local context can play a moderating role in the effect of policy design and administrative burden on take-up. The resources people and communities have to overcome burdens, the concentration of disadvantage, and the demand, or need, for these policy resources varies widely between and within states. I was recently awarded the Paul Volcker Junior Scholar Award for this research from the American Political Science Association.
   
In my first chapter, I demonstrate how Medicaid enrollment varies at the county-level and how concentrated disadvantage impedes enrollment using multilevel modelling. In counties with high proportions of people living below the federal poverty level, Medicaid enrollment is lower than in more mixed income counties. This negative effect is exacerbated (i.e. enrollment is even lower) in counties that are both poor and racially segregated. In my second chapter, I develop a method for measuring Medicaid take-up. Existing research on Medicaid take-up only looks at a snapshot in time, a single state, a small set of states, or a single eligibility group (e.g. pregnant women, childless adults, those over 65, etc.). I measure take-up monthly for all states and all eligible groups. I use multilevel regression, imputation, and post-stratification (MRP) to estimate how many people are likely eligible based on criteria that vary by state and by eligibility group. Then, I use those estimates and monthly administrative enrollment data to calculate take-up. In subsequent chapters, I develop measures of administrative burden and policy design for state Medicaid programs and use these measures to test the interactive effects of policy design, administrative burden, and state/local context on take-up. The first empirical chapter is completed, and I am nearly finished with data collection and fitting the MRP models for the remaining chapters.

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