The 2014 governors' races and health care: a campaign web site analysis.

The November 2014 midterm election was the first election since key coverage provisions of the Affordable Care Act (ACA) were implemented, including the Medicaid expansion and creation of the health insurance exchanges. The pre-election variability in the states' implementation of these provisions coupled with the large number of states selecting their next governor made the election important at the state level. To better understand the role of health care in the recent gubernatorial elections, we analyzed health policy content presented by 71 candidates for governor on their campaign Web sites. Nearly 80% of all candidates discussed health policy on their Web site, including the subset of the 36 winning governors. The predominant focus of health policy content was on the ACA as a whole or its provisions. Medicaid was discussed more often by candidates in non-expansion states than those from expansion states. Based on the statements of winning governors, we expect serious consideration of the Medicaid expansion to occur in at least 4 states, whereas 2 states may make efforts to reverse course. Relatively few winning governors (33%) mentioned the exchanges. Only 1 expressed interest in switching from the federal exchange to a state exchange, which has particular relevance given the Supreme Court's pending decision on King v. Burwell that could invalidate tax credits on the federal exchange. The prominence of health care in the gubernatorial campaigns strengthens the likelihood that governors will play an influential role in the health system's future, especially as the ACA undergoes further federal debate.

Introduction

The Republican Party’s strong performance in the November election—the first since the main coverage provisions of the Affordable Care Act (ACA) took effect—solidified a political landscape that favors continued debate on the health reform law.[1,2] The pre-election variability in states’ decisions to implement key ACA coverage provisions—primarily Medicaid expansion and health insurance exchanges[3-5]—coupled with the sheer number of states that cast ballots for governor in November 2014 (36 vs only 11 in 2012), made the election particularly important for the ACA’s future. We sought to answer the following research questions:

Research Question 1: What positions did gubernatorial candidates take on the ACA?

Research Question 2: Did they support or oppose expanding Medicaid?

Research Question 3: Did they support a state or a federal exchange in their state?

Methods

In October 2014, we reviewed the health policy content on the campaign websites of all candidates running for the 36 governorships (only 1 of the 72 candidates did not have a Web site). From all major party candidates’ official campaign Web sites, we systematically entered health policy content into a REDCap data extraction tool.[6] If candidates explicitly presented the ACA on their Web sites, we categorized their stance as either in favor or opposed to the ACA, recorded the reasons offered for any opposition, and if they used the term Obamacare. We then categorized all candidates’ views as either opposed to or supportive of Medicaid expansion in their state, and similarly classified whether they planned to change their state’s current exchange design (eg, from state to federal). Our primary analysis categorized our findings for the 36 winning candidates, stratified by political party; secondary analyses also considered losing candidates. We used chi-square, and Fisher exact tests when appropriate, to compare outcomes by political party.

Limitations

Our focus on governors is strategic given their unique, visible role in shaping their state’s policy agenda.[3,7,8] They can, however, be constrained by other state actors.[7,9,10] Nonetheless, their campaign statements may be indicative of their willingness to facilitate (or oppose) changes to health reform in their state.[11] In addition, campaign Web sites are a growing source of political data for capturing candidates’ issue positions. Although they are imperfect, studies have shown that they are reliable source for capturing a candidate’s policy views and comparable with other campaign communication that disproportionately favors well-funded candidates.[12-16]

Results

Nearly 80% of gubernatorial candidates (56 of 71) discussed health care on their campaign Web sites, with the predominant focus being the ACA or its coverage provisions. Republicans who mentioned the law overwhelmingly (90%) referred to it as “Obamacare,” whereas not a single winning Democrat used this term (though 4 losing Democrats did so). Among the winning governors, only 3 of 12 Democrats/Independent expressed favorable views on the ACA per se whereas the majority of the 24 Republican governors (62%) indicated opposition to the law (see Table 1). The top reasons for ACA opposition that these 24 Republicans offered were that it was “a failure” (53%), represented federal overreach into states (47%), raised premiums (47%), or caused plan cancellations (40%).

Table 1.

Presence of Health Policy Topic on the 36 Candidates Elected for Governor in 2014, by Political Party.

		Republican	Democrat/Independent[a]
	All winning candidates (N = 36)	N = 24	N = 12	P value[b]
Health policy on Web site	Yes, including ACA or ACA provisions	17 (71%)	8 (67%)	.81
	Yes, but nothing related to ACA or its provisions	3 (13%)	1 (8%)
	No mention of health policy	4 (16%)	3 (25%)
ACA position
Position	Favor	0 (0%)	3 (25%)	<.01
	Oppose	15 (62%)	0 (0%)
Framing	Unclear/complicated	0 (0%)	2 (17%)
	No explicit mention of ACA	9 (38%)	7 (58%)
	Of those who explicitly mentioned ACA	n = 15	n = 5	<.01
	Referred to ACA as “Obamacare”	13 (87%)	0 (0%)
Medicaid expansion
Expanded (elections in 21 of 28)[c]	Winning candidates in expansion states	n = 10	n = 11
	Support status quo (Medicaid expansion)	0 (0%)	3 (36%)	.19
	Change/reverse (move toward private plan)	2 (20%)	1 (9%)
	Mentioned Medicaid but not expansion policy[b]	0 (0%)	0 (0%)
	No mention of Medicaid	8 (80%)	7 (64%)
Not expanded (elections in 15 of 22)[d]	Winning candidates in non-expansion states	n = 14	n = 1
	Support status quo (no plans for expansion)	4 (29%)	0 (0%)	.33
	Change/reverse (move from traditional ACA Medicaid expansion toward private plan or vice versa)	2 (14%)	1 (100%)
	Mentioned Medicaid but not expansion policy[e]	2 (14%)	0 (0%)
	No mention of Medicaid	6 (43%)	0 (0%)
Exchange[f]
State exchange (elections in 19 of 23)	Winning candidates in states with state exchange	n = 9	n = 10
	Supportive of current exchange	3 (33%)	3 (30%)	.98
	Critical of current exchange (eg, poor implementation)	1 (11%)	1 (10%)
	No mention of exchange	5 (56%)	6 (60%)
Federal exchange (elections in 17 of 27)	Winning candidates in states with federal exchange	n = 15	n = 2
	Supportive of the current exchange situation	3 (20%)	0 (0%)	.14
	Critical of current exchange (eg, move to state-based plan)	0 (0%)	1 (50%)
	No mention of exchange	12 (80%)	1 (50%)
Examples of non-ACA topics[g]	Physician shortage (eg, increase residency slots; debt relief)	3 (SD, IA, OK)	3 (HI, AK, PA)
	Medical research and technology (eg, cancer)	3 (FL, GA, OH)	1 (RI)
	Mental health/substance abuse (eg, opiate control)	3 (OH, WY, TN)	4 (VT, CT, AK, NH)

Note. ACA = Affordable Care Act.

Of the 36 newly elected governors, 24 are Republicans, 11 are Democrats, and 1 is Independent.

P values are from Pearson’s chi-square test. Fisher’s exact test was used when subgroup n < 5.

States with elections that had expanded Medicaid in some form (n = 21) as of November 4, 2014, according to Kaiser Family Foundation (www.kff.org): AR, AZ, CA, CO, CT, HI, IA, IL, MA, MD, MI, MN, NH, NM, NV, NY, OH, OR, PA, RI, VT.

States with elections that had not expanded Medicaid (n = 15) as of November 4, 2014: AK, AL, FL, GA, ID, KS, ME, NE, OK, SC, SD, TN, TX, WI, WY.

Candidates may have mentioned exchanges or Medicaid expansion but provided no context linking these issues to federal law.

Exchange status as of November 4, 2014, comes from KFF (www.kff.org). States with a federal exchange were compared with states with state-run or partnership exchanges.

Additional non-ACA–specific health policy topics were presented on Web sites, such as primary care medical homes, but we have only listed those that were mentioned multiple times by members of both parties (and their corresponding state abbreviations). Campaign Web site content that corresponds with each position category is available on request.

Medicaid Expansion

Medicaid expansion was explicitly mentioned more by Democrats (49%) than Republicans (28%), especially those Democrats who lost in the 15 non-expansion states with elections. Among the 21 expansion states with elections, only 6 winning candidates (4 Democrats, 2 Republicans) discussed this policy (29%). Both Arizona and Arkansas elected new Republican governors who expressed willingness to shift away from traditional expansion under the ACA. In contrast, Pennsylvania’s new governor criticized his Republican predecessor’s plan to expand private coverage and instead favored a traditional expansion. Among non-expansion states with governors’ races, Republican candidates won 14 of the 15 elections. Half of the winning governors in these states mentioned Medicaid expansion on their Web sites, mostly reiterating opposition to expansion. But the governors of Wyoming and Tennessee supported customized expansion options as did Alaska’s newly elected Independent governor.

Exchanges

Less than one third of all candidates—regardless of political party—mentioned health insurance exchanges on their Web sites. Among the winning candidates who discussed exchanges, 33% generally supported the current arrangement in their state, though 2 operating state-based exchanges expressed concerns with its rollout. Only 1 of the 17 governors in states using the federal exchange (Pennsylvania) expressed support for switching to a state-based exchange.

Discussion

Although some suggested that the ACA would fade as an issue once the law was implemented,[17] we find evidence that the health reform law—and health policy more broadly—was an important issue discussed on most candidates’ campaign Web sites. However, opponents of the law were much more vocal than supporters of the law. Republican governors were more likely to mention their opposition to the ACA (“Obamacare”) whereas Democrats distanced themselves from the law and generally did not mention it explicitly.

We also observed different strategic choices from the 2 parties regarding the Medicaid expansion, in part depending on each state’s expansion status.[18] Few winning governors from expansion states discussed this policy. For Republican candidates, this likely reflects not only a balancing act between the ACA’s general unpopularity with their constituents[2,19] but also potential political consequences of taking away a tangible benefit that has already been given and is popular among those who have received it.[18,20] Facing these 2 alternatives, it was easiest for many Republicans simply not to discuss Medicaid at all. Republican candidates from Arizona and Arkansas, however, challenged this notion as they stated their intentions to potentially reverse course on the Medicaid expansion. Meanwhile, Democrats in expanding states avoided discussing the expansion, likely due to the ongoing divided public opinion about the law.[19]

In non-expansion states, candidates from both parties discussed Medicaid more frequently. Republicans won over 90% of these elections and generally continued to oppose expansion, overcoming Democratic candidates’ efforts to make the expansion a prominent campaign issue.[3,21] However, winning Republican candidates in 2 states (Tennessee and Wyoming) expressed plans to explore Medicaid expansion options even while expressing strong opposition to the ACA, likely in an attempt to balance their states’ politically hostile environment toward the ACA with Medicaid budgetary pressures.[22,23]

Finally, we found little evidence that the exchanges were a prominent election topic. However, days following the election, the Supreme Court announced its decision to hear the King v. Burwell case, which brings uncertainty to the legality of tax credits for those in federal exchanges.[24] Had this announcement come during the election cycle, it is unclear how candidates from the 17 states with a federal exchange would have engaged with this issue.

These findings suggest that the ACA remains a key gubernatorial election issue, though more so for ACA opponents than its supporters. The campaign positions expressed by the 36 winning governors indicate that many of them—especially Republicans—are willing to spend political capital to shape the ACA’s future in their state. Although several may expand Medicaid, others may reverse course. Finally, the stakes for state-based decision making regarding the ACA will only increase if the Supreme Court rules against the administration in King v. Burwell. Overall, our results suggest that the ACA remains a hot-button issue for policymakers and worth studying as an election issue in forthcoming campaigns—both among state and federal leaders, legislators, and executives alike.