Year of Publication



Public Health

Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Julia Costich, J.D., Ph.D.

Committee Member

F. Douglas Scutchfield, MD

Committee Member

Tyrone Borders, PhD



This study aims to analyze policy-related and political rationales for Medicaid expansion under the Patient Protection and Affordable Care Act (PPACA). More specifically, this study seeks to discover whether states’ decisions regarding Medicaid expansion were likely based on policy implications regarding the uninsured or political motives.


The approach is a cross-sectional/observational study of American states and the District of Columbia after the Sebelius decision in 2012. This study compares three variables: (1) whether each state decided to opt into the expansion (“Opted In”), (2) whether each state’s governor and legislature were affiliated with either the Democratic or Republican party at the time of its decision (“Party”), and (3) the potential impact of Medicaid expansion on the uninsured population of each state (“Uninsured”). “Opted In” is the dependent variable; “Party” is the political variable; and “Uninsured” is the policy variable. This study utilized analysis of variance (ANOVA), chi-squared testing, and hypothesis testing between statistics to analyze relationships between variables.


For the study sample (N = 38), data analysis found statistically significant relationships between: (1) uninsured rates and decisions regarding Medicaid expansion; (2) political party affiliation and decisions regarding Medicaid expansion; and (3) political party affiliation and uninsured rates in respective states. States with higher rates of uninsured citizens were less likely to opt into the Medicaid expansion. Republican states were less likely to opt into the expansion than Democratic states. Democratic and Republican states had statistically different rates of uninsured citizens, with Republican states having higher rates than Democratic states.


Results suggest both policy and political motives influence executive and legislative decision-making. The direction of influence of policy implications regarding the uninsured is inconsistent with PPACA’s policy goal of reducing the uninsured population. However, Republican states have higher rates of uninsured citizens than Democratic states. Therefore, inconsistencies may be incidental to overall political influence and social structure within states. Greater public health advocacy may help to overcome political barriers to achieving the policy goals of legislation.

Included in

Public Health Commons