Which US States Are Most Generous in Their Medicaid Policies and Why?

Why are some states more generous in their welfare programs than others? Although this question has been widely studied in comparative political economy, it has been less applied to US health policy. Delegation of Medicaid administration to the states has produced substantial variation in program generosity, but the sources of this variation remain underexplained. This article analyzes predictors of Medicaid generosity using longitudinal data from 2000-2020 on state eligibility and enrollment rule generosity. It tests several political economy theories, including left power resources, racial/ethnic heterogeneity, political culture, and partisan politics. Findings show strong variation in generosity across states and generosity categories, although overall generosity has increased over time. Political culture-particularly conservative mass attitudes-shows the most consistent negative effect on generosity. Racial heterogeneity also predicts lower generosity. By contrast, Democratic trifectas and union strength (measures of left power resources) show no consistent effects, whereas Republican trifectas correlate with higher administrative burden and reduced eligibility but not other generosity measures. Overall, political culture shapes Medicaid generosity more consistently than party control does, suggesting that public preferences for limited government play a key role in shaping state policy. The article concludes by discussing implications for the present moment, as the scope of Medicaid coverage is poised to be dramatically reduced.