Could Medicaid Coverage Losses Dampen Voter Turnout?

Research Corner
November 6, 2023

Soleil Shah, MD, MSc, Research Reporter

Soleil Shah writes Tradeoffs’ Research Corner, a weekly newsletter bringing you original analysis, interviews with leading researchers and more to help you stay on top of the latest health policy research.

Can losing Medicaid coverage make someone less likely to vote? That’s the timely question guest author Gabriella Aboulafia tackles in this week’s Research Corner. Whether you’re heading to the polls today, or you’re thinking ahead to the critical votes you’ll cast this time next year, I think you’ll find this column fascinating.

I’ll be back next week with a look at New York City’s ambitious effort to extend health care to thousands of undocumented residents. See you then!

Could Medicaid Coverage Losses Dampen Voter Turnout?

By Gabriella Aboulafia, MPP

Gabriella Aboulafia is a first-year PhD student in the political analysis track of Harvard University’s interdisciplinary health policy program. She’s interested in the politics of health reform, and how people’s experiences with public insurance programs shape perceptions of government and political participation.

Around this time next year, millions of Americans will head to the polls for a critical Election Day. Millions of others will not.

One factor keeping people home — according to an interesting and growing corner of health policy research — could be a wave of Medicaid coverage losses. Roughly 10 million people have lost this form of public insurance since April 2023, when states were allowed to resume kicking beneficiaries off of their Medicaid rolls for the first time since the COVID-19 pandemic began.

This so-called Medicaid unwinding is the largest change to the country’s health insurance landscape since the enactment of the Affordable Care Act (ACA).

Several studies suggest that the ACA’s massive expansion of Medicaid coverage had electoral consequences — and that made me wonder if this huge loss of that coverage might also affect elections.

Medicaid losses linked to lower voter turnout in Tennessee

The closest parallel I could find comes from a 2019 study by Jake Haselswerdt and Jamila Michener, published in the Journal of Health Policy, Politics and Law. The pair of researchers looked at what happened to political participation in Tennessee after the state’s Medicaid program (known as TennCare) cut benefits in 2004 for 170,000 enrollees (3% of all Tennesseans).

Haselswerdt and Michener used the unequal distribution of coverage losses across the state’s counties to assess how these changes affected voter turnout. Using county-level data from the state’s 2002 and 2006 gubernatorial elections (both of which coincided with Senate race and midterm elections), the authors found that counties with larger coverage losses saw larger drops in voter turnout between 2002 and 2006.

In those counties where voter turnout declined, the authors found that for every one percentage-point drop in Medicaid enrollment there was a decrease in voter turnout ranging from about a quarter (.24) to a third (.36) of a percentage-point. The researchers didn’t observe a significant impact on how the vote split along party lines.

These drops in voter turnout may not sound that big, but keep in mind that states like Mississippi, Louisiana and Kentucky — all of which have governors up for election this month — have seen their Medicaid enrollment drop by an average of 6 percentage points since they resumed disenrollments. This unwinding process will continue across the country through next year, when many more political offices, including the presidency, will be on the ballot.

Stigma and state policy differences make the unwinding’s political impact harder to predict

One important limitation of this study is that it looks at only one state — and we know that both Medicaid policy and politics vary widely across the country. We also know that some people losing their Medicaid coverage will pick up coverage from another source, like their employer or the ACA marketplaces.

It is also worth remembering that while people in many states are experiencing coverage losses, a few states (South Dakota, Nebraska, and soon, North Carolina) have expanded their Medicaid programs to more people since the last presidential election.

Other research by the paper’s coauthor Jamila Michener makes one other important point. Even people whose Medicaid coverage survives this unwinding may not be as likely to vote.

Michener has documented through qualitative interviews that beneficiaries have complex feelings about this public program, which is rooted in a history of structural racism and stigma. Those feelings can dampen political engagement.

One big reason, Michener has found, is because the Medicaid program itself — and how it is administered — leave many people feeling disempowered and distrustful of the state.

When I read the stories coming out of this current unwinding — of people caught in bureaucratic mazes and paperwork mistakes leading to life altering losses of insurance coverage — I can’t help but predict those feelings of distrust and disempowerment will only grow. And we could see their impact at the ballot box.