Dissertation
Inaccessible by design: policy design, administrative burden, and the politics of medicaid take-up
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Summer 2024
DOI: 10.25820/etd.007606
Abstract
Many Americans do not enroll in the social safety net programs for which they are eligible. This is partly because these programs require potential enrollees to navigate confusing and cumbersome administrative procedures and eligibility requirements. When assessing policy outcomes, such as enrollment, it is essential to consider how the policy is implemented, not just its design. Administrative burdens, which are the difficulties people face when applying for or using a government program, are a crucial aspect of policy implementation. When a policy offers generous benefits, we expect enrollment to be high, but if applications are complex and difficult to complete, many eligible people may be unable to enroll. This dissertation shows an interactive effect of policy design and implementation on program take-up, and it also demonstrates that the political determinants of policy design changes differ from those for changes to administrative burdens. These findings highlight the complexities of policy implementation and how they pose potential barriers to program take-up.
Focusing on Medicaid, the US health insurance program for people of all ages with low incomes and high healthcare costs, I introduce a new dataset that measures Medicaid take-up, policy design, and administrative burdens to demonstrate these effects. I show that state political and social contexts constrain policy design decisions, but administrative burden changes are often passed in response to state needs. I find support for an interactive effect between policy design and administrative burden. As a state’s administrative burden for Medicaid increases, the effect of the program’s generous design on take-up decreases. Even if a program offers generous benefits, if the burden is too high, an applicant may decide it is not worth it or possible to complete the application process. I also find a negative and statistically significant interaction effect for states’ administrative burden easing, which suggests that there is likely a tradeoff between policy generosity and burden easing. These insights can guide researchers and policymakers in finding the right balance between policy generosity and administrative burden, ensuring that the Medicaid program is accessible and sustainable.
Details
- Title: Subtitle
- Inaccessible by design: policy design, administrative burden, and the politics of medicaid take-up
- Creators
- Tracee M Saunders
- Contributors
- Frederick Boehmke (Advisor)Rene Rocha (Committee Member)Julianna Pacheco (Committee Member)Bryce Dietrich (Committee Member)Jamila Michener (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Political Science
- Date degree season
- Summer 2024
- Publisher
- University of Iowa
- DOI
- 10.25820/etd.007606
- Number of pages
- x, 163 pages
- Copyright
- Copyright 2024 Tracee M Saunders
- Language
- English
- Date submitted
- 07/19/2024
- Description illustrations
- illustrations, tables, maps, graphs
- Description bibliographic
- Includes bibliographical references (pages 105-115).
- Public Abstract (ETD)
- Many eligible Americans do not enroll in Medicaid, the US health insurance for people of all ages with low incomes and particularly high healthcare costs. This is partly because these programs require potential enrollees to navigate confusing and cumbersome administrative procedures and eligibility requirements. In this dissertation, I aim to understand better why we see mismatches between eligibility and enrollment and how policy design and policy implementation affect the mismatch. To do this, I introduce a new dataset that includes state Medicaid policy design decisions, over 200 measures for how complicated a state’s application processes are, and a new measure for Medicaid take-up, which is the ratio of enrolled individuals to eligible individuals. I analyze how states change their Medicaid programs and application processes using this new data. I find that changes to the program (e.g., eligibility requirements or benefits offered) are constrained by state political and social contexts, while changes to application processes (e.g., making it easier to enroll) tend to be more responsive to state needs for Medicaid. I also analyze how states’ Medicaid program design and application processes affect Medicaid take-up. States with more generous Medicaid programs have higher take-up, but complex application processes can interfere with this positive effect. Even if a state’s Medicaid program offers generous benefits, if the application process is too complicated, enrollment suffers, and many who are eligible do not receive benefits.
- Academic Unit
- Political Science
- Record Identifier
- 9984698352302771
Metrics
2 Record Views