Process Learning and the Implementation of Medicaid Reform

As the implementation of health care reform proceeds in the face of ongoing political conflict, variations in state decisions are shaping important aspects of its pace and scope. This article investigates five potential explanations for state implementation of the Medicaid expansion—state party control, economic affluence, the trajectory of established policy, state administrative capacity, and the process of learning from intergovernmental bargaining. Our analysis of fifty states finds, not surprisingly, that party control of government influences state decisions. We also find, however, several additional and striking influences on states—namely, the trajectory of established policy for vulnerable populations and, of particular importance, state learning about the process of intergovernmental bargaining.