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Literature Review: Findings Assignment: Why are some states more
resistant to support federal health care policy?
Literature Review Assignment #2 for Week/Module Five
Michael C. Bland
Dr. William Bowen
Liberty University
PLCY 804-Summer 2022
June 12, 2022
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Literature Review: Findings Assignment: Why are some states more
resistant to support federal health care policy?
Introduction
The concept of federalism forms an idea that enhances the relationship between the
central/federal government and state governments. This means that federal and state
governments were established with separate powers, autonomy, and responsibilities. In critical
sectors, such as healthcare, federalism plays an important role in determining and separating
federal and state governments’' roles. In the United States, the federalism debate is centered on
how strong the federal government should be, what responsibilities belong to the central
government, and instances where state autonomy should reign. For instance, in healthcare, states
have financial and administrative roles to play while the federal government provides substantial
funding and oversight role. However, the appropriate balance between the two responsibilities
has sparked a considerable debate in the country, with some arguing for a greater federal role in
healthcare while others are for more devolution of responsibilities to the states. The cooperative
federalism model/theory can best explain the separation of powers and autonomy between the
two levels of the government-the federal government and state governments. This is because
cooperative federalism allows federal and state agencies to carry out governmental programs
collectively without giving a clear line of powers and responsibilities between the two levels of
government.
This paper examines why some states are more resistant to supporting federal health care
policy. The paper seeks to answer the research question, "Why are some states more resistant to
support federal health care policy?” The previous literature review paper provided a theoretical
framework for exploring this research question “Why are some states more resistant to support
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federal health care policy?” I incorporated cooperative federalism and Biblical concepts to
explore the research question. In the current paper, I will review existing empirical studies
related to the research question to establish what is already known on why some states are more
resistant to support federal health care policy and identify the literature gap that studies should
seek to fill on the topic.
Findings From the Analysis
Glunk & Nicole (2018) conducted a study to measure states' cooperation, sovereignty,
and autonomy in federal healthcare policy-making. Their study sought to establish whether
federalism, which provides separate powers, autonomy, and responsibilities between the federal
and state governments, can influence states’ cooperation with federal healthcare policies. Their
study found that states were individual republics and sovereign governments different from each
other (Glunk & Nicole, 2018). This means that every state is distinguishable from the other. Thus
intrastate politics and the expression of state sovereignty play a critical role in resisting federal
health care policies such as Medicaid expansion. Since not all states have the same legal and
constitutional structure, states implement federal health care policy differently. Some states can
embrace the policy and implement it without hesitation, while others may be reluctant to
implement the policy. Therefore, state sovereignty, autonomy, independence, and politics
influence the implementation of federal healthcare policies.
Jacobs & Callaghan (2013) conducted a study to explore factors that lead to variations in
the implementation of Medicaid among states across the United States. In their analysis, Jacobs
& Callaghan (2013) found that three factors are responsible for those variations. The first factor
relates to gubernatorial statements, budgets, and decisions of the governor to expand or not
expand Medicaid. Secondly, states that receive and accept federal grants are more determined to
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implement federal reforms than those that do not receive and accept such grants. Therefore,
states that do not accept federal grants are disinterested and less prepared to implement federal
reforms compared to their counterparts that accept and receive those grants (Jacobs & Callaghan,
2013). Finally, changes in Medicaid policy that states took in 2013 affect its implementation in
some states. Changes such as the expansion of the benefits, simplification of the application
process, and enhancement of its renewal process are some of the issues that influence its
adoption by states.
However, these factors that lead to variations in the adoption and implementation of
Medicaid and other healthcare reforms are influenced by political party polarization. In their
study, Jacobs & Callaghan (2013) found that states with stronger Democratic power are moving
faster in adopting and implementing Medicaid compared to their Republican counterparts, who
have slower and inactive progress towards the implementation of the policy. These findings are
consistent with those of a study by Rigby & Jake (2013), who investigated the impact of
partisanship on federal health care policy implementation. Rigby & Jake (2013) found that
partisan politics determines how early states move to implement federal health care policies.
In another study to understand state resistance to patient protection and the Affordable
Care Act (ACA), Lischko & Waldman (2013) found that political factors in states' refusal to
support and implement ACA account only for 18 states. There is a shifting pattern in the
implementation of this healthcare policy witnessed in the recent past. For instance, Republican-
dominated states like Arizona, Ohio, and North Dakota have expressed their desire to implement
Medicaid expansion, while there are some Democratic-dominated states that are still considering
whether to expand Medicaid. Lischko & Waldman (2013) found that the budget factor plays a
critical role in determining states' resistance or acceptance of implementing federal policies. In
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Medicaid, states were required to fund a portion of the Medicaid expansion by 5 percent begging
2017 and gradually increase their contributions to 10 percent each year up to 2020 (Lischko &
Waldman, 2013). Although states are required to provide a small percentage of the total funding,
any federal policy that leads to additional costs to the states is likely to face resistance.
Nicholson-Crotty (2012) examined the reasons why some state governments have refused
federal grants aid over the last 50 years. The study findings suggested that partisanship and
electoral pressure play an important role in influencing governors' application and
implementation of federal aid grants. The study showed that Republicans refused federal grants
in 2010 and 2011 due to partisan influence (Nicholson-Crotty, 2012). This means that states
whose governors were from a different party than the president refused to implement federal
grants meaning partisanship are critical in influencing state resistance to federal policies.
Barrilleaux & Carlisle (2018) conducted a study to determine governors' decisions to
support or oppose Medicaid expansion under the PPACA. Although the support of federal
programs such as the PPACA should depend on the need of the individual state, this study found
a significant influence of politics in supporting federal policies. Barrilleaux & Carlisle (2018)
found that governors' partisanship and composition of the legislature had a meaningful influence
on governors' decisions to support or oppose PPACA, and thus the study concluded that politics
outweigh the citizens' needs and state economic condition in influencing governors' support or
opposition of PPACA.
In another study to examine why some states are opposed to federal healthcare policy,
Travis et al. (2018) explored the choices made by states in accepting and implementing the
PPACA. The study found a significant effect between southern states' governors' choices and
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politics than in other states. These findings are consistent with those of Barrilleaux & Carlisle
(2018), that found that politics influence governors' decisions to support federal programs.
Franz et al. (2021) also conducted a study with the aim of exploring whether ACA
opposition is racially influenced or not. The study found that efforts to block ACA’s passage and
to dismantle it or repeal its statute may have appealed to some white voters because it is seen as a
handout for the underserved poor non-white communities (Franz et al., 2021). This study's
findings are consistent with those of Milner et al. (2020), who found a strong relationship
between anti-black attitudes and opposition to the ACA. Thus, stronger anti-black attitudes by
the whites are a critical barrier to the implementation of federal health care policies in the United
States. These studies found a significant relationship between the opposition to ACA and racism,
suggesting that racism and racial sentiments play a critical role in influencing federal health
policy debates.
Pacheco et al. (2020) also conducted a study to examine the role of partisan state elites in
influencing federal policy, such as the PPACA support and implementation. The findings of this
study suggest that in a highly polarized national debate such as the ACA, Republican partisans
respond negatively when a Democrat governor announces support for Medicaid expansion but
respond positively when a Republican governor does so. Democrats, on the other hand, remain
unmoved in both scenarios. Therefore, these findings suggest that the Democrat governor's
support for a federal health care policy leads to polarization in the state. Thus state-level partisan
political elites have a significant influence on state position on federal health care policies
(Pacheco et al., 2020).
Application
The studies reviewed above support the research question, "Why are some states more
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resistant to support federal health care policy?” and dependent and independent variables in my
study in the following ways. Glunk & Nicole (2018) support cooperation federalism theory in
influencing state support or opposition of federal health care reforms. The study argues that
states' sovereignty, autonomy, and independence influence the implementation of federal health
care policies. Additionally, Jacobs & Callaghan (2013) support my dependent variable (state
opposition to federal health care policy). Rigby & Jake (2013) also use a variable state
opposition to federal health care policy, and thus the study is compatible with my dependent
variable.
Furthermore, Lischko & Waldman (2013) support my dependent variable as their study is
aimed at understanding why some states oppose federal health care policy. Nicholson-Crotty
(2012) also supports my study as its aim is to determine factors that influence governors' refusal
of federal aid grants, which is consistent with my dependent variable. Moreover, Barrilleaux &
Carlisle (2018) are consistent with my study as they seek to determine what factors influence the
governor's choice in opposing or accepting federal health care programs and thus support my
dependent variable.
The study by Travis et al. (2018) is also compatible with my study as it supports my
dependent variable. The study explored the choices made by states in accepting and
implementing the PPACA and thus supports my study that seeks to establish why some states are
resistant to federal health care policy. Studies by Franz et al. (2021) and Milner et al. (2020)
support my study by providing more exploration of the dependent variable, as their findings
suggest that racism plays a critical role in influencing state support for federal health care
programs. Finally, Pacheco et al. (2020) support my dependent variable; they seek to establish
the role of partisan political elites in opposition to federal health care policies. The study is
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compatible with my study, which seeks to establish reasons why some states resist federal health
care policy.
Conclusions
Conclusively, this study has found substantial evidence that supports why some states are
resistant to federal health care policy. The reviewed empirical studies have found that state
autonomy and sovereignty play a major role in influencing the adoptability and implementation
of federal health care programs. Studies have also found that politics plays a critical role in
influencing the state’s support for federal health care policies such as the PPACA. The reviewed
studies have also supported the role of partnership in influencing governors’ decisions in
accepting or refusing federal aid grants. Furthermore, budget and additional costs to state
budgets can also influence the acceptance and implementation of federal health care reforms.
Finally, the reviewed studies have shown that anti-black attitudes and racial sentiments also play
a critical role in opposing federal health care programs in the United States, where most whites
perceive federal health programs such as the ACA as a handout for the underserved poor non-
white communities.
These findings in the literature review are important to my study because they all support
my dependent variable (state opposition to federal health care policy). The studies reviewed seek
to explore reasons why some states are resistant to federal policies and thus are compatible with
my study, which seeks to examine why states resist federal health care policy. Therefore, the
studies reviewed support my dependent variable and cooperation federalism theory that explains
the separation of powers and autonomy between the two levels of the government-the federal
government and state governments.
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1. Topic: Federalism and Healthcare Policy
2. Research Question: Why are some states more resistant to support federal health care
policy?
3. Database(s) Searched: JSTOR, Google Scholar, Academic Search, Journal of
Federalism, and Journal of Health Politics, Policy, and Law.
4. Keywords used in Search: Health policy, federal/ state government, federalism, ACA,
PPACA, health equity, Medicaid expansion, politics, governors, partisanship, federal
grants aid
Author/Date Keywords Findings Application to
Question
Barrilleaux &
Carlisle (2018)
Health policy,
public policy,
federal/state,
federalism,
governors, politics,
legislative politics
Governors’ partisanship and
composition of the
legislature have a meaningful
influence on governors'
decisions to support or
oppose PPACA, and thus
politics outweigh the
citizens’ needs and state
economic condition in
influencing governors’
support or opposition of
PPACA.
This study is
consistent with my
study as it seeks to
determine what
factors influence the
governor's choice in
opposing or
accepting federal
health care programs
and thus support my
dependent variable.
Franz et al.
(2021)
Racism, ACA,
Health equity,
Efforts to block ACA’s
passage and to dismantle it
Supports my study by
providing more
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policy, health
disparities
or repeal its statute may have
appealed to some white
voters because it is seen as a
handout for the underserved
poor non-white communities.
exploration of the
dependent variable as
their findings suggest
that racism plays a
critical role in
influencing state
support for federal
health care programs.
Glunk & Nicole
(2018)
Federalism,
healthcare policy,
state sovereignty,
Medicaid
expansion,
state/federal
governments
States were individual
republics and sovereign
governments different from
each other. This means that
every state is distinguishable
from the other. Thus
intrastate politics and the
expression of state.
Sovereignty plays a critical
role in resisting federal
health care policies such as
Medicaid expansion.
Supports cooperation
federalism theory in
influencing state
support or opposition
of federal health care
reforms.
Jacobs &
Callaghan
(2013)
Health reforms,
Medicaid
expansion,
PPACA, States,
Factors that lead to
variations in the adoption
and implementation of
Medicaid and other
Supports my
dependent variable
(state opposition to
federal health care
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Medicaid adoption healthcare reforms are
influenced by political party
polarization. States with
stronger Democratic power
are moving faster in adopting
and implementing Medicaid
compared to their
Republican counterparts,
who have slower and
inactive progress towards the
implementation of the policy.
policy.
Lischko &
Waldman (2013)
ACA, politics,
PPACA, state
resistance,
bipartisan support,
partisanship
The budget factor plays a
critical role in determining
states' resistance or
acceptance of implementing
federal policies. Federal
programs adding costs to the
state’s budget are opposed to
those which are fully funded
by the federal government.
Supports my
dependent variable as
their study is aimed
at understanding why
some states oppose
federal health care
policy.
Milner et al.
(2020)
Racism, health
equity, policy,
ACA, implicit bias
There is a strong relationship
between anti-black attitudes
and opposition to the ACA.
Supports my study by
providing more
exploration of the
dependent variable as
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their findings suggest
that racism plays a
critical role in
influencing state
support for federal
health care programs.
Nicholson-
Crotty (2012)
Federal grants aid,
governors,
partisanship, grant
distribution,
federalism
Partisanship and electoral
pressure play an important
role in influencing governors'
application and
implementation of federal
aid grants. The study showed
that Republicans refused
federal grants in 2010 and
2011 due to partisan
influence.
Supports my study as
its aim is to
determine factors that
influence governors’
refusal of federal aid
grants, which is
consistent with my
dependent variable.
Pacheco et al.
(2020)
ACA, politics,
policy,
partisanship,
polarization,
governors, federal
reforms
implementation
In a highly polarized national
debate such as the ACA,
Republican partisans respond
negatively when a Democrat
governor announces support
for Medicaid expansion but
respond positively when a
Republican governor does
Supports my
dependent variable,
they seek to establish
the role of partisan
political elites in
opposition to federal
health care policies.
The study is
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so. Democrats, on the other
hand, remain unmoved in
both scenarios.
compatible with my
study, which seeks to
establish reasons why
some states resist
federal health care
policy.
Rigby & Jake
(2013)
Federalism,
partisan politics,
state health
insurance
exchange
Partisan politics determines
how early states move to
implement federal health
care policies.
Use a variable state
opposition to federal
health care policy,
and thus the study is
compatible with my
dependent variable.
Travis et al.
(2018)
Implementation of
the Patient
Protection
and Affordable
Healthcare Act
(PPACA), Sothern
states, non-
southern states
There is a significant effect
between southern states'
governors' choices of federal
health care policies and
politics than in other states.
Compatible with my
study as it supports
my dependent
variable. The study
explored the choices
made by states in
accepting and
implementing the
PPACA and thus
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supports my study
that seeks to establish
why some states are
resistant to federal
health care policy.
References
Barrilleaux, Charles, and Carlisle Rainey. 2014. "The politics of need: Examining governors'
decisions to oppose the “Obamacare” medicaid expansion." State Politics & Policy
Quarterly 14, no. 4: 437-460.
Franz, Berkeley, Adrienne N Milner, and R. Khari Brown. 2021."Opposition to the affordable
care act has little to do with health care." Race and social problems 13, no. 2: 161-169.
Gluck, Abbe R., and Nicole Huberfeld. 2018. "What is federalism in healthcare for." Stan. L.
Rev. 70: 1689.
Jacobs, Lawrence R., and Timothy Callaghan. 2013."Why states expand Medicaid: Party,
resources, and history." Journal of health politics, policy and law 38, no. 5: 1023-1050.
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Lischko, Amy, and Beth Waldman.2013. "Understanding State Resistance to the Patient
Protection and Affordable Care Act: Is It Really Just Politics as Usual." J. Health &
Biomedical L. 9: 101-134.
Milner, Adrienne, and Berkeley Franz.2020. "Anti-black attitudes are a threat to health equity in
the United States." Journal of Racial and Ethnic Health Disparities 7, no. 1: 169-176.
Nicholson-Crotty, Sean. 2012. "Leaving money on the table: Learning from recent refusals of
federal grants in the American states." Publius: The Journal of Federalism 42, no. 3: 449-
466.
Pacheco, Julianna, Jake Haselswerdt, and Jamila Michener.2020. "The Affordable Care Act and
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Rigby, Elizabeth, and Jake Haselswerdt. 2013. “Hybrid Federalism, Partisan Politics, and Early
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Federalism 43(3): 368–91.
Travis, Rick, John C. Morris, Martin Mayer, Robert Kenter, and David A. Breaux.2018.
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