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. 2026 Jan-Mar;51(1):32-42.
doi: 10.1097/HMR.0000000000000459. Epub 2025 Nov 14.

The contingent effects of hospitals' campaign contributions on Medicaid expansion after the Affordable Care Act

Colby D Green, Douglas A Schuler, Carson D Cannon, Richard B Scoresby

The contingent effects of hospitals' campaign contributions on Medicaid expansion after the Affordable Care Act

Colby D Green et al. Health Care Manage Rev. 2026 Jan-Mar.

Abstract

Background: This paper examines the campaign contributions made by hospitals and their employees to state legislators in the years following the Affordable Care Act, during the period in which hospitals sought Medicaid expansion in all 50 states.

Purpose: The purpose of this research was to identify the institutional characteristics in which campaign contributions are an effective management tool for obtaining favorable policy.

Methods: In this study, we combined archival data from the Kaiser Commission on Medicaid and the Uninsured, the National Institute on Money in State Politics, the National Conference of State Legislatures, and the U.S. Census Bureau from 2010 to 2015. The analysis uses a two-stage residual inclusion Cox proportional hazards model to estimate the conditional effects of hospitals' state-level campaign contributions on the hazard of Medicaid expansion.

Results: In this analysis, it has been demonstrated that campaign contributions increased the likelihood of Medicaid expansion in states with large legislative districts but decreased the likelihood of Medicaid expansion in states in which a single political party controls the executive and legislative branches. This research concludes that the effectiveness of campaign contributions is contingent on characteristics of local legislative institutions.

Practice implications: Our findings encourage health care administrators to assess the institutional environment before engaging in political activities. Dollars contributed to campaigns in states with large legislative districts are likely to be effective, whereas dollars spent in states with unified governments are likely the least effective. In these latter contexts, health care administrators are encouraged to seek alternative methods of policy influence.

Keywords: Affordable Care Act; Medicaid expansion; corporate political activity.

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