Wal-Mart welfare: Business, fiscal regime, and the politics of health policy in the American states

In the search for ways to cover the millions of uninsured Americans, state governments across the country have attempted one solution more frequently than any other: expanding eligibility to the public health care programs for the poor and near poor, Medicaid and the State Children's Health Insurance Program (SCHIP). There are two primary explanations for this convergence. First, the federal government provides huge incentives for states to choose this strategy, in the form of substantial matching funds. Second, these programs represent a changed American welfare state in which (A) states have new policy autonomy and (B) antipoverty policies increasingly emphasize work. As a result, "Wal-Mart Welfare" programs---that is, policies that have implications for low-income workers, their families, and their employers---are more popular among the public, elites of both parties, and the business community than their traditional welfare forebears. Given these factors, why do we see such variation in the ability of expansion proposals to survive the legislative process? Why are only some states able to move the status quo?;Through an investigation that includes a 50-state quantitative analysis and interview-based case studies of South Carolina, California, and Maryland, the dissertation argues that Wal-Mart Welfare policy battles are rooted in fiscal politics. That is, political debates are not about the proper role of government in social provision, but about money: how much exists, where it can be found, and how much there will be in the future. In choosing from the range of potential financing options, policy entrepreneurs are limited by the willingness and capacity of state lawmakers to access different kinds of money, including general funds and various taxes. This willingness and capacity is shaped by three types of fiscal constraints: fiscal rules, fiscal norms, and employer preferences. The funding strategies chosen and the political forces that limit and respond to these choices ultimately determine the trajectory of expansion proposals and their likelihood of legislative success.