The Patient Protection and Affordable Care Act (ACA) gives states the option—with very generous federal financing—to provide coverage to all low-income Americans. After 2014, new Medicaid enrollees will makeup more than 25% of total enrollment in many states that choose to expand coverage. While the federal government’s financial offer to expand Medicaid eligibility is hugely significant, the ACA’s treatment of Medicaid is consistent with Medicaid’s evolution as gradually expanding into the American middle-class. Medicaid was our nation’s largest health insurance program a decade before health care reform. From the start, Medicaid’s intergovernmental design with a generous federal matching rate and substantial state discretion has led to continual expansions and pushed Medicaid in this middle class direction. The ACA solidifies this middle class development. If this is true, if Medicaid has expanded into a middle-class entitlement on par with Social Security and Medicare, one would expect this gradual expansionary development to have culminated into new political demands where Medicaid recipients and family members would fight to maintain and expand Medicaid coverage.

This paper, using data from Kaiser Family Foundation Health Tracking Poll, examines the extent to Medicaid has evolved into a middle-class entitlement where (current and potential) constituents put pressure on state politicians to maintain or expand benefit levels, and state politicians in turn find it difficult to rescind Medicaid benefits. We will examine this questions in two ways: first, by considering the impact of public opinion for Medicaid expansions on state Medicaid decisionmaking; and second, the impact of potential constitutient demand on state Medicaid decisionmaking. The likelihood of adopting state Medicaid expansion policies is estimated as a function of: public support for Medicaid in each state, party control of the state government, provider interest group strength and the state safety-net market, the federal matching rate and other state demographic characteristics. We hypothesize that all else equal, states with higher levels of public support, and higher potential demand, will be associated with states adopting more generous Medicaid eligibility policies. These analyses help illuminate the extent to which, and the unique ways in which, Medicaid has evolved into a middle-class entitlement.