Public Management Review

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Qualitative Comparative Analysis and Public

Services Research: Lessons from an Early
Application

Martin Kitchener , Malcolm Beynon & Charlene Harrington

To cite this article: Martin Kitchener , Malcolm Beynon & Charlene Harrington (2002) Qualitative
Comparative Analysis and Public Services Research: Lessons from an Early Application, Public
Management Review, 4:4, 485-504, DOI: 10.1080/14616670210163033

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Published online: 09 Dec 2010.

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Abstract QUALITATIVE
This ar tic le int ro duces the qua litative
com para tiv e ana lysis (QCA) method ,
COMPARATIVE
pr ovides a detailed des cript ion of a n
early a pplication in US pub lic ma nag e - ANALYSIS AND
PUBLIC SERVICES
me nt rese arch and d raws les sons fro m
the expe rience. In me thod olo gical

RESEARCH
term s, we show that QCA requ ire s
cod ing dec isions that inf luence o ut -
com es significantly and empha s ize that
this se conda ry data ana lysis tech niq ue
Lessons from an early
be used in con junc tion with p rimar y
me thods in or der to con sider iss ues of application
pr oces s . The sub sta ntiv e findings from
our a pplication in a stu dy o f state- level
barrier s to policy diffus ion indicate the
Martin Kitchener, Malcolm Beynon
potential of QCA as a system atic and Charlene Harrington
app roach to the iden tification of link -
age s between caus a l factors that
Martin Kitchener and Charlene Harrington
em erge a s impo rtan t to case s tudy
Department of Social and Behavioral Sciences
participan ts.
University of California, San Francisco
3333 California Street, Suite 455
San Francisco
California, 94118, USA
Tel: 1 1 415 502 7364
Key words Fax: 1 1 415 476 6552
Qualitativ e comp a rative a nalysis (QCA),
E-mail: martink@itsa.ucsf.edu
long -term care, health po lic y a nd
ma nageme nt
Malcolm Beynon
Cardiff Business School
Cardiff University
Colum Drive
Cardiff, CF10 3EU
Wales, UK
Tel: 1 44 (0)29 2087 5747
Fax: 1 44 (0)29 2087 4419
E-mail: BeynonMJ@cardiff.ac.uk

Vol. 4 Issue 4 2002 485–504

Public Management Review ISSN 1471–9037 print/ISSN 1471–9045 online
© 2002 Taylor & Francis Ltd http://www.tandf.co.uk/journals
DOI: 10.1080/14616670210163033
486 Public Management Review

INTRODUCTION

The most in uential qualitative research textbooks now describe computer-based
approaches that claim to relieve researchers of tedious tasks and encourage the pursuit
of theoretical and empirical connections that might otherwise remain unexplored (see,
for example, Denzin and Lincoln 1994; Miles and Huberman 1994). In the USA,
Drass and Ragin’s (1992) Qualitative Comparative Analysis (QCA) has emerged as a
leader among these approaches following expert endorsement and the publication of
applications in studies of social phenomenon including: ‘reality shock’ among newly
qualiŽ ed teachers (Huber and Garcia 1991), policy development (Hicks 1994) and
labor management practices in textile mills (Coverdill and Finlay 1995).
Although Ragin (1999) recently advocated the use of QCA in public services
research, he gave few details on the practical application of the method or the
methodological pros and cons of its use. The four main sections of this article address
these issues directly for the public services Želd. The Žrst section introduces the basic
principles of QCA and the second describes the research goals we sought to address
by applying QCA in a study of barriers to policy diffusion in the USA. The third
section provides a detailed description of our application of QCA. The fourth section
discusses our substantive Ž ndings to illustrate the type of insights provided by QCA.
The concluding section considers methodological issues relating to QCA and provides
guidelines for future applications in public services research.

QCA: AN INTRODUCTION

A perspective on causal complexity, necessity and sufŽciency

In public services research, as in other Ž elds, a common strategy in comparative case-

oriented studies is to analyze a small to moderate number of cases in which a focal
event (outcome or process) has occurred, or is occurring (e.g. Pettigrew et al. 1992).
Typically, this approach involves a search for antecedent conditions shared by all (or
virtually all) instances of the focal event, with an eye to understanding how these
conditions Ž t together to produce the outcome. While the assessment of these factors
is important for public services, designs that work backward from multiple instances
of an event to identify shared antecedent conditions (1) cannot address sufŽ ciency and
this may fail to identify decisive causes, and (2) make restrictive assumptions about
causation, namely, that theoretically relevant, nontrivial necessary conditions exist. In
contrast, Ragin (1999: 1228) argues that while the search for necessary conditions is
useful, it can be more fruitful to allow for the possibility of causal complexity.
Causal complexity refers to the fact that many of the outcomes that interest social
scientists result from multiple combinations (conŽ gurations) of factors (causal condi-
tions). When causation is this complex – probably the rule rather then the exception
 Kitchener et al.: QCA and public services research 487

in public services research – no single causal condition is either necessary (present in

all cases of the focal outcome) or sufŽ cient (almost invariably followed by the
outcome). Faced with these conditions, case study researchers often adopt a mode of
analysis that involves searching for similarities among cases in order to develop
typologies. This means, rather than viewing their cases as instances of the ‘same thing’,
researchers differentiate types of outcomes and try to identify causal commonalities
within each type, and differences between types. While this approach has generated
important theoretical insights and advances, types can proliferate to the point where
the number of cases conforming to each type may be quite small. The potential for this
outcome stems in part from an emphasis on the search for commonalities, understood
as necessary conditions; but it is also an effect of the rigidity of the notion underlying
it: that each outcome must result from a single causal condition or single combination
of conditions. Once the likelihood of causal heterogeneity is acknowledged, the
decision to typologize becomes less straightforward and alternative analytical approa-
ches are worthy of consideration.
One alternative to searching for necessary-but-not-sufŽ cient causal conditions (i.e.
studying causal commonalities shared by instances of an outcome) involves working
forward from causal conditions, especially combinations of conditions, to assess their
sufŽ ciency. To assess the sufŽ ciency of a cause or causal combination, the researcher
must determine whether or not the causes in question always, or virtually always,
produce the focal outcome. Evidence that there are instances in which the causes are
not followed by the focal outcome challenges the researcher’s claim that the cause is
sufŽ cient. The assessment of sufŽ ciency, therefore, involves searching for cases that are
similar with respect to the relevant causes and then assessing whether or not these
cases display the same outcome. QCA is a computer-based method that addresses this
task and helps identify from case study data, the causal paths that lead to a focal
outcome (causal heterogeneity).

The basics of QCA

QCA combines the concerns of two research traditions. On one hand, QCA draws on
the general principles of analytical induction to employ variables derived from
(grounded in) case study evidence (Glaser and Strauss 1967; Strauss and Corbin
1990). In addition, QCA addresses the primary concern of variable-oriented research
to observe patterns across cases (Miles and Huberman 1994: 173). Unlike conven-
tional statistical analysis, however, QCA does not ask about the independent effect of
a variable on the likelihood of an outcome. Rather, it considers conŽ gurations of values
on the independent variables as cases (Ragin 1987; Drass and Ragin 1992). As an
alternative to searching for necessary but not sufŽ cient causal conditions (those
important in some but not all cases), QCA works forward from conditions identiŽ ed
in distinct cases (especially combinations of conditions) and assesses their sufŽ ciency
across cases.
488 Public Management Review

QCA software (which may be downloaded free from the Internet site http://
www.nwu.edu/sociology/tools/qca/qca.html) uses Boolean algebra to implement a
mode of logical comparison through which each case is represented as a combination
of causal and outcome conditions (Ragin et al. 1984). Computer algorithms compare
these combinations and simplify them logically through a bottom–up process of paired
comparison. The objective is to reduce the unique conditions to the minimum
combinations of factors necessary for the outcome of interest to occur. The result of
this minimization process is a ‘truth table’ that depicts the different combinations
of conditions deriving the focal outcome. Thus, in contrast to inferential statistical
methods, and of particular value to public services research, QCA helps to identify
from sets of grounded variables, the multiple causal paths to a focal outcome (Ragin
1987).

QCA TO EXPLORE LINKAGES AMONG BARRIERS TO POLICY DIFFUSION

The primary aim of our 1999 federally funded study was to identify the linkages
between factors that participants in US state long-term care (LTC) systems perceived
as barriers to the expansion of a program that seeks to expand the provision of home
and community-based services (HCBS). This is a central concern for public services
research because state governments face three pressures to extend the provision of
HCBS such as home health and personal care (Kitchener and Harrington 2001). First,
the public increasingly displays a preference for LTC services provided at home rather
than from institutions such as nursing homes and state mental hospitals (Kaye and
Longmore 1998). Second, citizens’ access to HCBS is encouraged within: (a)
legislation such as the 1990 Americans with Disability Act, and (b) legal judgments
including the 1999 Olmstead Supreme Court decision (Rosenbaum 2000). Third,
concerns continue to mount regarding the quality of institutional LTC (Institute of
Medicine (IoM) 2001).
Medicaid – the federal/state health program for low-income individuals – pays for
approximately 44 percent of LTC expenditures and since 1981, the Medicaid 1915(c)
HCBS waiver program has offered states federal matched funding to expand HCBS and
accelerate movement away from LTC services provided from institutions (Harrington
et al. 1998). This optional program allows the federal Department of Health and
Human Services to ‘waive’ certain statutory requirements regarding states’ Medicaid
plans so they can expand HCBS in two main ways. First, states can target HCBS
toward speciŽ c geographical areas (i.e. a county), populations (e.g. the elderly) and
conditions (e.g. traumatic brain injury). Second, they can provide HCBS services not
otherwise covered by state Medicaid plans (e.g. respite care, home modiŽ cations, case
management and adult day care).
Despite the pressures for change and the incentives offered to states under the
waiver program, in 1997, institutional care still consumed 75 percent of Medicaid
 Kitchener et al.: QCA and public services research 489

LTC dollars (Burwell 1999). Within this general pattern of inertia, in 1998 there was
great variation in the diffusion of the waiver program across the states. For example,
per capita state waiver expenditures ranged from $96.22 per person in Vermont to
$3.94 in Mississippi, and waiver participants per 1,000 people ranged from 7.91 in
Oregon to 0.62 in Indiana (Harrington et al. 2000a).
While previous studies of innovation diffusion in healthcare and other Ž elds portray
organizational ‘receptivity’ to change (Pettigrew et al. 1992) along a continuum
between proactive ‘innovators’ and less responsive ‘laggards’ (Rogers 1983), case
studies of HCBS development have concentrated on innovator laboratories such as
Oregon and Wisconsin. The Ž ndings of these case studies emphasize, but fail to explore
the linkages between, factors such as constraints on nursing home bed supply and
supportive local political conditions (e.g. Clark and Rhodes 1994; Ladd et al. 1995;
Coleman et al. 1996). The less common regression analyses of nationwide data present
(from sets of variables derived from the research literature) statistically signiŽ cant
predictors of receptivity HCBS including: Democratic governors, higher average
personal incomes and higher home health reimbursement rates (Harrington et al.
2000a; Miller et al. 2001).
The primary aim of this study was to reŽne these understandings of HCBS
development by using case study evidence to explore linkages among the factors that
participants in LTC systems view as barriers to the diffusion of the HCBS waiver
program.

QUALITATIVE COMPARATIVE ANALYSIS OF LAGGARD STATES

This application of QCA was conducted – and is reported – across four stages: (1)
pre-QCA activity involving case sampling and the identiŽ cation of causally relevant
characteristics; (2) coding of variables and the production of a raw data matrix; (3)
running QCA software to produce a truth table, minimizing causal terms and testing
their sufŽ ciency; and (4) interpretation of results.

Stage 1: Pre-QCA activity – case sampling and condition identiŽcation

Pre-QCA activity involves two main activities, the selection of cases and the
identiŽ cation of causal attributes. While Ragin (1999) suggests that sampling for QCA
should involve, where possible, the universe of relevant cases, the detailed study of all
Ž fty state LTC systems was not possible in this study. Neither was it appropriate for
our primary goal of exploring causal complexity among barriers in laggard states.
Thus, this study selected for in-depth analysis, a ‘purposive’ sample (Miles and
Huberman 1994) of Ž ve states (Illinois, Louisiana, Mississippi, Nevada, Pennsylvania)
from among those with lower levels of state per capita spending/participation rates on
HCBS waiver programs (see Table 1).
490 Public Management Review

Tab le 1: Ide ntifying the lagga rds

Illinois Louisiana Mississippi Nevada Pennsylvania

(Rank) (Rank) (Rank) (Rank) (Rank)

Medicaid participants/1,000 117 171 184 63 85

pop. (US av.126)
Medicaid per capita $482 $536.52 $521 $302 $390
expenditure (US av. $461)

# HCBS waivers 1999 8 4 3 4 8

Waiver participants/1,000 3.07 (15) 0.63 (49) 0.75 (45) 0.9 (44) 0.91 (43)
pop. (1997) US av. 2.1

HCBS waiver expenditures $20.96 (33) $11.51 (47) $3.93 (49) $5.64 (44) $31.53 (25)
per capita 1997 (US av.
$29.4)

HCBS waiver expenditures $6,838 $18,312 $5,287 $6,243 $34,747

per participant 1997 (US av.
$14,016)
Note: Waiver data rankings out of 49 states as Arizona and Washington DC have nil waivers.
Source: Harrington et al (2000a: Tables 2 and 3).

In line with requirements for QCA (Ragin 1987, 1999), this sample was designed
to be small enough to permit familiarity with each case to ensure integrity of the set,
yet large enough to warrant interest in cross-case patterns. As Table 2 shows, beyond
the similarities outlined in Table 1, the case states provide variety in terms of size,
region, per capita income, population density and other socio-demographic charac-
teristics.
In each case study (state), qualitative data relating to the study aims were collected
from three main sources: (a) 10–15 semi-structured, face-to-face and telephone
interviews with state ofŽ cials, and various consumer and professional organization
representatives; (b) internal reports and other documents; and (c) a public forum on
HCBS conducted in each state in the spring of 1999. During each forum, consumers
and advocates gave their perspectives on the development of local HCBS programs
(transcription of the forum testimonies are available on request). Additional participant
and expenditure data relating to the state waiver programs were collected from annual
statistical reports for the period 1992–7. The aim of triangulating these multiple
sources of evidence was to enhance the credibility of the study Ž ndings by increasing
the amount and quality of data, and examining multiple perspectives (Yin 1999).
The data collection and analysis was conducted by a Ž ve-person team with nearly
sixty years of combined research and work experience in the LTC Ž eld. While sub-
groups took the lead on research efforts in the case states, analysis followed a common
 Kitchener et al.: QCA and public services research 491

Tab le 2: Selec te d socio- demog raph ic cha racter istics of samp le stat es

Illinois Louisiana Mississippi Nevada Pennsylvania

(Rank) a (Rank) b (Rank) c (Rank) d (Rank) e

Total pop. 1998 12,045,326 4,368,967 2,752.092 1,746,898 12,001,451

(5th) (22nd) (31st) (36th) (6th)
% pop. age 65+ 1998,(US 12.4 11.5 12.2 11.5 12.7
av.12.7)

% pop. age 85+ 1998 1.5 1.3 1.5 0.9 1.8

(US av. 1.5)

% pop. White 1997 81.3 (36th) 66.2 (48th) 62.6 (49th) 86.4 (29th) 88.6 (24th)
(US av. 82.7)

% pop. Black 1997 15.3 (15th) 32.1 (3rd) 36.4 (2nd) 7.5 (25th) 9.7 (21st)
(US av. 12.7)

% pop. Hispanic 1997 9.9 (10th) 2.6 (29th) 0.8 (48th) 15.1 (5th) 2.5 (31st)
(US av. 10.9)

% pop. Minority 1997 18.7 33.8 37.4 13.6 11.4

(US av.18.1)

Persons/1000 with self care 246.9 313.2 347 205.6 245.4

difŽ culty 1990 (US av. 247)

% pop.unemployed 1996 5.3 6.7 6.1 5.4 5.3

(US av. 5.4)
% pop. in poverty 1997 11.6 18.4 18.6 9.6 11.4
(US av. 13.5)

% pop. in metropol. areas 84.1 (13th) 75.2 (21st) 35.3 (46th) 85.7 (10th) 84.6 (11th)
1996 (US av. 79.8)
Infant deaths/1,000 live 8.4 9.5 10.6 6.5 7.6
births 1997 (US av.7.2)
% low birth weight 1996 8.0 10.1 10.1 7.7 7.6
(US av. 7.5)
AIDS rate/100,000 1998 10.8 21.8 15.1 14.8 14.5
(US av. 17.1)

Violent crimes/ 100,000 pop. 886 (5th) 929 (4th) 488 (25th) 811 (8th) 433 (28th)
1996 (US av. 634)
% pop.not covered by health 11 (40th) 20.5 (4th) 19.7 (6th) 18.4 (8th) 9.9 (42nd)
insurance 1995 (US av. 15.4)
Notes:
a
Summarized from, and original sources cited in, Newcomer et al. (2000b: 2).
b
Summarized from, and original sources cited in, Harrington et al. (2000b: 5).
c
Summarized from,and original sources cited in, Harrington et al. (2000c: 6).
d
Summarized from, and original sources cited in, Harrington et al. (2000d: 4).
e
Summarized from, and original sources cited in, Newcomer et al. (2000a: 4).
492 Public Management Review

protocol. On data analysis sheets, patterns and themes were coded (Strauss 1988)
from the case materials in an attempt to make intuitive sense of the evidence and
identify the local barriers to the extension of the waiver program. When a new barrier
emerged, this triggered an inductive cycle in which it was assessed by the researchers
in terms of whether it appeared ‘probable, reasonable or likely’ to be in uential (Miles
and Huberman 1994: 431). The situation of the entire research team at a common
institutional base allowed for frequent meetings and less formal discussions. This
feature is important because the threat of early identiŽ ed barriers becoming Ž xed or
over-stated was reduced by their reassessment as new evidence emerged, and through
regular debate among the team.
From team-based reviews of the case data analysis sheets, six main barriers were
identiŽ ed for detailed consideration: (a) Republican governors; (b) relatively stringent
state eligibility requirements for Medicaid; (c) relatively high supply of nursing home
beds; (d) poor state Ž nances; (e) a strong local nursing home industry lobby; and (f)
a weak consumer lobby (relative to the opposing lobby). These barriers became the
causally relevant conditions (independent variables) for our QCA (for a discussion of
alternatives methods see, Amenta and Poulsen 1994). Paying particular attention to
the six barriers, descriptive case reports were prepared for each state: Illinois
(Newcomer et al. 2000b), Louisiana (Harrington et al. 2000b), Mississippi (Harrington
et al. 2000c), Nevada (Harrington et al. 2000d) and Pennsylvania (Newcomer et al.
2000a).

Stage 2: Coding of conditions and construction of data matrix

For QCA, the focal outcome (laggard state) and each of the six casually relevant
conditions needed to be reduced to a dichotomous variable for each state, i.e. one that
could be coded ‘present’ (1) or ‘absent’ (0). The coding of the outcome measure and
each of the six causally relevant conditions is detailed below.

c LAGGARD (Outcome): States with lower than average per capita HCBS waiver
spending are coded 1, others are coded 0.
c REPUBLICAN: States with Republican governors in 1999 are coded 1, others
are coded 0.
c ELIGIBILTY: States with Medicaid eligibility threshold more stringent than the
US average are coded 1, others are coded 0.
c NURSING HOME BEDS: States with higher than national average nursing home
beds per 1,000 persons are coded 1, others are coded 0.
c WEAK ADVOCACY: States with less well-organized and weaker HCBS advocacy
groups are coded 1, others are coded 0.
c STRONG LOBBY: States with a better-organized and more powerful nursing
home industry lobby are coded 1, others are coded 0.
 Kitchener et al.: QCA and public services research 493

c DEFICIT: States with a 1997 budget deŽ cit or projected deŽ cit are coded 1,
others are coded 0.

Because the selection criteria for state sampling considered both per capita waiver
expenditures and participation rates, Pennsylvania displayed higher than average per
capita spending and was coded 0. This, in effect, re ects a weak laggard coding as
opposed to the 1 coding that re ects a strong laggard status. For the attributes weak
advocacy and strong industry lobby, each state was coded relatively based on the
research team experience and assessment of case evidence (see Table 3).
Tables 3 and 4 display the required outcomes of the second stage of QCA. Table 3
shows in a raw data matrix, the results of the coding operation and a summary of the
case study evidence relating to each causally relevant factor for each of the sample
states (further case evidence is displayed in the case reports cited earlier). Table 4
displays these data in the form required by QCA software whereby each row
represents a state and each column represents an observed causally relevant condition
(variable).

Stage 3: QCA

Following manual entry of the data matrix, the QCA software (version 3.1) performed
three steps of analysis. This produced three main outputs: (a) a truth table comprising
sixty-four rows of causal conŽ gurations; (b) three conŽgurations of causal conditions
associated with the low per capita expenditure on HCBS waiver programs; and (c) a
series of comparisons to determine which aspects of these conŽ gurations are logically
necessary and/or sufŽ cient to laggard states. Because descriptions and illustrations of
the computational process by which QCA software generates and minimizes configura-
tions are provided elsewhere (e.g. Coverdill and Finlay 1995: 468), the following
description concentrates on the Ž rst and second stages of QCA.

Construction of a ‘truth table’

Whereas conventional methods of quantitative methods would analyze the data matrix
(Table 4) directly and by case, QCA software converts data in the matrix to form a
‘truth table’. This device deŽ nes all logically possible combinations of the causal
conditions using a present/absent dichotomy. In this study of the six variables thought
to in uence the outcome of laggard states, there exist 26 or sixty-four possible
combinations (six of these represent those cases that were observed empirically). At
this stage, rather than conceiving cases (states) as collections of ‘scores’ on the six
variables, the observed states recede into the background. The analytical spotlight is
concentrated on each unique conŽ guration of causal attributes (the six observed cases
plus the Ž fty-eight logically possible combinations). Each is treated as a distinctive
 494

Table 3: Raw data m atrix of cas e state s

Illinoisa Louisianab Mississippic Nevadad Pennsylvaniae

Public Management Review

1. Republican governor Yes 20 years Yes 3 years Yes, 8 years Yes, 1 year Yes, 4 years
(1999) (George Ryan) (Mike Foster) (Kirk Fordice)f (Kenny Guinn)g (Tom Ridge)

2. Medicaid eligibility Y Y Y Y N
threshold tighter than SSI No SSPh No SSP, no medically No SSP, no medically SSP: $36 per month SSP: $32 in community,
(Y/N) needy program needy program aged, $375 for blind per $329 in domiciliary care,
month, $330 aged $334 in personal care
domiciliary care. No homes. Special income
medically needy program allowance, medically
needy program
3. Nursing homes beds/ 72.3 83.8 52.1 21.7 51.2
1,000 pop. +65 (1998)
Above US av. 53.1 (Y/N) Y (+36%) Y (+58%) N N (–41%) N

4. HCBS advocacy Weak, fragmented Weak, fragmented Weak, fragmented Weak, fragmented Strong but fragmented
groupsi
Table 3: contin ued

Illinoisa Louisianab Mississippic Nevadad Pennsylvaniae

5. Nursing home industry Strong Strong Strong Weak Strong

lobbyj

6. State Ž nancial statusk FY 1999, budget ending
balance $1.351 following
high balances previous 2
years
FY 1997, state reported a FY budget balance of In 1997, the state The FY 2000 budget
zero ending balance and approximately $4million experienced a budget passed the largest tax
no budget stabilization shortfall and a ‘zero cuts in the stateís history,
fund. In1999, estimated a budget balance’ in more than$400 million.
$400 million deŽ cit in 1998–9. In addition, nearly $1
Medicaid programs billion was placed in a
‘rainy day account’ (p.6)

Weak ? N Y N Y N

Notes:
a
Newcomer et al. (2000b).
b
Harrington et al. (2000b).
c
Harrington et al. (2000d).
d
Harrington et al. (2000c).
e
Newcomer et al. (2000a).
f
Fordice retired in December 1999 and was replaced in January 2000 by Democrat Ronnie Musgrove.
g
Guinn replaced Democrat Bob Miller in 1998.
h
SSP – State Supplemental Payment(optional SSI income.)
i
Case reports, forum testimony, expert evaluation.
j
Case reports forum testimony, expert evaluation.
k
Case reports.
Kitchener et al.: QCA and public services research
495
496 Public Management Review

Tab le 4: Data m at rix of cas e stat es

Strong
Laggard Nursing Weak industry Budget
State (outcome) Republican Eligibility home beds advocacy lobby deŽ cit

IL 1 1 1 1 1 1 0
LO 1 1 1 1 1 1 1
MS 1 1 1 0 1 1 0
NV 1 1 1 0 1 0 1
PA 0 1 0 0 0 1 0

Note:At this stage, each row represents an observed state and its characteristics.

‘whole’ or case. The fact that any one conŽ guration represents one state, four states or
no observed states does not matter. Each is given the same weight, as each represents
a single conŽ guration of causal attributes.
Following the most common approach to coding the outcomes of the logically
possible but empirically unobserved conŽ gurations, they were not discarded (see
Coverdill and Finlay 1995). Rather, they were coded as ‘don’t care’ (with a dash). This
allowed the QCA program to mechanistically assign an outcome (strong or weak
laggard) based on which code produced the most parsimonious solution (see later).

Minimization by comparison
Following the assignment of outcome codes to the unobserved conŽ gurations, the
QCA software performs a series of paired comparisons between those conŽ gurations
that differ only in one respect – namely, in the presence or absence of a given attribute
when all other attributes are identical. This simpliŽ cation entails dropping that item
(the causally irrelevant term) from a pair of conŽ gurations to derive a simpler
equation. This produced the following three minimized (‘prime implicant’) equations
of states’ low per capita spending in HCBS waiver programs:

Laggard states 5
REPUBLICAN ELIGIBILITY NURSING HOME BEDS WEAK ADVOCACY STRONG LOBBY 1

REPUBLICAN ELIGIBILITY WEAK ADVOCACY STRONG LOBBY deŽcit 1

REPUBLICAN ELIGIBILITY Nursing home beds WEAK ADVOCACY strong lobby DEFICIT

These three equations specify in a logically minimal way, the different combinations
of values on the causal conditions that are linked with the outcome LAGGARD.
Following Ragin’s (1987) notation method, the combinations are joined by a plus sign
and notated as an equation that uses attribute codes. Codes in upper case letters
indicate the presence of an attribute; codes in lower case letters indicate absence. The
 Kitchener et al.: QCA and public services research 497

plus sign indicates multiple causation because each conŽ guration of values on the causal
variables are linked to the outcome LAGGARD. The logic of QCA places equal weight
to each term, even if they represent different numbers of observed states.
Two features of the QCA simpliŽcation process that derived these prime implicant
equations are signiŽ cant. First, the process of paired comparison requiring that two
conŽ gurations differ only in one respect means the importance of any given attribute
for LAGGARD cannot be evaluated apart from the other attributes. Second, the
simpliŽ cation process is context speciŽ c in the sense that an attribute can be
understood as unimportant in one context but critical in others (e.g. non-inclusion of
deŽ cit in prime implicant 1 compared with inclusion in prime implicants 2 and 3).
Indeed, two of our prime implicants do not include each of the six attributes we
thought might be important in causing LAGGARD states.

Stage 4: Assessing the causes of LAGGARDS

In substantive terms, this application of QCA suggests that LAGGARD states result
from three sets of causal conditions or, put another way, there are three ‘paths’ (Ragin
1987) to states’ low per capita spending on HCBS waivers. Since Republican
governors, stringent Medicaid eligibility and weak consumer advocacy are present in
each prime implicant equation they are described as logically necessary for unreceptive
contexts for HCBS waivers. States do not appear to be laggards under other
conditions. However, because these conditions do not appear as the only attributes in
any of the prime implicant equations, they are not logically sufŽ cient for the
occurrence of laggard states. This means that, Republican governors, stringent
Medicaid eligibility and weak consumer advocacy produce LAGGARDS only under
certain other conditions.
The QCA Ž ndings indicate that in states with the three necessary conditions, three
different combinations of attributes push the state toward low per capita spending on
HCBS waiver programs. Any one in conjunction with the three necessary attributes
will derive low spending per capita on HCBS waivers. So, the combination of high
numbers of nursing home beds and a strong industry lobby (prime implicant 1) is
causally equivalent to both: (a) the effect of having a strong industry lobby and strong
state Ž nances (prime implicant 2); and (b) the impact of having low numbers of
nursing home beds, a weak industry lobby and a state budget deŽ cit. These three
combinations have the same effect; they are causal substitutes or different paths to the
same outcome.
These substantive Ž ndings, which we did not have without the use of QCA, have
important implications for public services research and policy. The primary concern of
the study was that contrary to the intention of federal policy makers and the wish
of HCBS advocates, after twenty years of the HCBS waiver program, institutional care
still consumed 75 percent of Medicaid LTC dollars. This application of QCA to case
498 Public Management Review

study evidence suggests that future research and reform advocacy work be directed
toward three state-level barriers: Republican governors, stringent Medicaid eligibility
requirements and weak consumer advocacy. These Ž ndings underscore general asser-
tions regarding the importance of state-level political conditions for Medicaid policy
diffusion that emerge from: (a) case studies of receptive contexts for HCBS (e.g. Clark
and Rhodes 1994; Ladd et al. 1995; Coleman et al. 1996); and (b) regression analyses
of nationwide statistical data (Cromwell et al. 1997; Harrington et al. 2000a; Miller et
al. 2001).
The reported association of having a Republican governor and being a laggard state
is consistent with Ž ndings that states with Democratic governors have higher rates of
per capita spending on HCBS waiver programs (Harrington et al. 2000a; Miller et al.
2001). As Grogan (1994) pointed out, the political ideology of the ruling state elite
plays a signiŽ cant role in policy and spending decisions; Republican governors tend to
promote more conservative spending patterns and make efforts to limit the new
spending required to expand the HCBS waiver programs. As Kronebusch (1997: 848)
notes, both political parties often attempt to appeal to elderly and disability
constituent groups, but these appeals may not translate equally into spending decisions
(see also, Cook and Barrett 1992).
While space precludes detailed exposition here, the rich contextual detail presented
in our case reports extends these insights to provide clear illustrations of how, for
example, some Republican governors restrict the generosity of HCBS reimbursement,
the expansiveness of eligibility and the coverage of services. This signals the need for
reform advocates to (a) ‘appeal to the hearts’ of Republican governors – possibly
through activities such as the cake campaign in Louisiana (Harrington et al. 2000b) –
and, (b) make HCBS expansion a campaign issue. It also conŽ rms Ž ndings from an
application of QCA to the development of health policy in Florida that emphasizes the
importance of change advocates fragmenting the in uence of interest groups con-
cerned with resisting change (Harkreader and Imershein 1999: 171).
The key reŽ nement to existing understandings of barriers to the extension of the
HCBS waiver program concerns the countervailing implications of state-level con-
sumer advocacy and the nursing home lobby. As this study conŽ rms with speciŽ c
regard to the waiver program, the effectiveness of political advocacy groups does play
a role in encouraging higher state spending on Medicaid programs (Kronebusch 1997).
The elderly and physically disabled contingencies can be particularly effective in
advocating for Medicaid services especially as the size of the elderly population
increases (Kane et al. 1998). As other constituencies such as those with mental
disabilities and traumatic brain injury become aware of HCBS services, they may also
begin to have political results in encouraging new programs or increased spending for
HCBS waiver programs. The Ž ndings of weak advocacy in LAGGARD states reinforce
the importance of studying advocacy organizations and identifying ways to enhance
their activities and impact.
Finally, this study conŽ rms that state Medicaid eligibility policies in uence strongly
 Kitchener et al.: QCA and public services research 499

the standards and criteria for receiving Medicaid services. Those states with the most
stringent Medicaid eligibility standards are more likely to control their Medicaid
enrollment and overall costs in general (Cromwell et al. 1997). These Ž ndings are also
consistent with previous studies showing states with limited Medicaid eligibility (such
as the dollar thresholds for the categorically and medically needy programs) are more
likely to limit access to optional programs such as HCBS waivers (Harrington et al.
2000a; LeBlanc et al. 2001). This signals the need for the disparate (and sometimes
competing) groups of HCBS advocates to organize and redouble the campaign for
more generous and more  exible state-level Medicaid eligibility requirements.

CRITICAL ASSESSMENT OF QCA FOR PUBLIC SERVICES RESEARCH

QCA provided this study with an approach to analyzing causal complexity based upon
conditions that emerged as signiŽ cant to participants. This represents a signiŽ cant
departure from statistical methods – such as regression analysis (Miller et al. 2001) and
typologizing through cluster analysis (Bazzoli et al. 1999) – that employ variables
selected by researchers from the literature. Two of the causal conditions used in this
study (the relative strength of consumer advocacy and the nursing home industry)
were not employed within regression analyses of nationwide data regarding the
diffusion of HCBS waivers (Miller et al. 2001). The valence of the QCA approach is
signaled by the fact that both of these causal conditions emerged to be necessary (if not
sufŽ cient) factors within the prime implicant equations.
QCA also offered this study an opportunity to combine numerical data collected
from the case studies with more purely qualitative data and assessments that did not
emerge in quantiŽ ed formats. Critics may claim that this merely represents an attempt
to quantify the qualitative data. We stress, however, that this computerized method of
analysis may facilitate a more systematic and complete exploration of alternative causal
explanations from case data than is possible using conventional approaches to
comparative case analysis. Beyond these positive issues, this early application of QCA
in pubic services research draws attention to seven methodological issues.
First, in common with some other methods of data analysis, QCA represents a static
approach in the sense that it does not consider dynamism among variables over time
(Ragin 1987). In the present application, only those attributes that emerged as
signiŽ cant to participants during the 1999 study are included. For studies of policy
diffusion, in which histories of conditions such as state governorship in uence and
constrain program diffusion (Kronebusch 1997), the QCA method must be augmented
with primary approaches to the reporting and interpretation of case research. In the
present application, for example, while each of the observed cases had a Republican
governor in 1999, the implications of this attribute have to be assessed against the
‘sociological calendar’ (Light 1975: 1145) of features such as the length of incumbency
and the afŽliations of previous post holders (see Table 3).
500 Public Management Review

Second, as with other approaches to comparative policy analysis (Leichter 1997),

the selection of the QCA outcome measure is both critical and potentially contentious.
Following previous studies (e.g. Harrington et al. 2000a), the present article used the
states’ per capita spending on the Medicaid 1915(c) waiver program as the measure of
unreceptive contexts for HCBS. Of course, alternative measures exist such as waiver
participants per 1,000 population. The signiŽ cance of this issue was demonstrated
when, after running QCA using this alternative outcome measure, the prime
implicants were exactly the same conŽ gurations of variables that formed the observed
cases. No minimization of either causal conditions or conŽ gurations was possible.
Our detailed case reports also signal the potential for disagreement regarding the
selection of QCA outcome measures in public services research. In Pennsylvania and
Illinois, for example, ofŽ cials claimed that while their per capita spending on HCBS
waivers is low, HCBS are extended through state-only Ž nanced programs. This
strategy, they argue, offers the state better opportunities to control cost and maintain
local control. Critics counter that these state programs are not direct substitutes for
HCBS waivers because: (a) they do not target underserved populations such as the
uninsured; and (b) they are more subject to the vagaries of the state economic cycles
(e.g. Cromwell et al. 1997; Mollica 2001).
Third, QCA might encourage consideration of a small number (n) of causal
attributes to reduce the complexity of the resulting truth table that expands to the
order of 2n conŽ gurations. This will deter those qualitative researchers who cannot
imagine investigations of social processes in which the number of causal attributes is
constrained. This study reports the use of six causal attributes, more than some other
reported applications of QCA (e.g. Ž ve in the case of Coverdill and Finlay 1995). For
exploration purposes, we ran the software program using seven and eight variables. A
key issue to emerge was that as the number of attributes increases, so does the relative
number of truth table rows that represent unobserved cases. Because all rows are
considered in QCA, as the number of causal attributes increases, the exercise becomes
more detached from empirical reality and more a test of logical possibilities. This also
seems to reduce the likelihood that the QCA software can minimize the number of
conŽ gurations from the data matrix.
Fourth, the ‘holistic’ nature of the method is stressed at the outset of the process
(pre-QCA) and then in later stages when cases are again treated as complex
conŽ gurations of attributes. As Coverdill and Finlay (1995: 462) note, during the
middle phase (coding), tensions may arise from the cognitively difŽ cult requirement to
detach from knowledge of the observed cases in order to code attributes in isolation.
While we went to great lengths to code on the basis of evidence, the tension appeared,
for example, during the less concrete evaluation of the strength of HCBS advocacy.
Fifth, as a method of cross-case analysis, QCA requires comparable information for
every case. This posed no particular problem for this study because a research protocol
was established from the outset. It may inhibit those who adhere more strictly to the
inductive ideology and principles of the ‘grounded theory’ approach to case research
 Kitchener et al.: QCA and public services research 501

(Glaser and Strauss 1967). QCA is, however, in tune with several of the techniques
that Strauss and Corbin (1990) propose for enhancing ‘theoretical sensitivity’.
Consistent with the grounded theory prescription to hone-in on phrases and initial
judgments such as ‘always’, the later stages of QCA led this study to explore in more
detail, the preliminary observation that all laggard states had Republican governors.
This application of QCA emphasizes that while this causal condition is present in each
of the three prime implicants, other facilitating conditions need to be present to
produce unreceptive contexts for HCBS waivers.
A sixth issue concerns the coding of causal conditions in QCA, an issue common in
many statistical techniques including multivariate discriminant analysis. In some cases,
coding in a dichotomous manner was relatively straightforward, as in the coding of
governor. In other cases, we used state performance against national averages to
determine the binary (0/1) coding of attributes (for discussion of alternative methods
see Ragin 1987: ch. 13). Coding of the industry and advocacy organization was more
subjective and is open to alternative interpretation from other researchers. Coverdill
and Finlay (1995: 474) illustrate that changing the coding of just a few cases on one
variable inuences the determination of prime implicants signiŽ cantly. Ragin (1999)
suggests that a resolution to this issue will arise from the development of a new
version of QCA software, which will be able to analyze truth tables composed of fuzzy
sets.
Finally, with respect to another coding issue, before QCA considers the configura-
tions among the case states, the problem of coding the outcomes of unobserved cases
has to be addressed. This arises, in part, because QCA is deterministic in the sense that
a given conŽguration of causal attributes cannot produce ‘contradictory’ outcomes (see
Kangas 1994). Unlike other approaches to data analysis such as variable precision
rough set theory (Beynon et al. 2000), the QCA software has no error term or means
of probabilistic causation to account for different outcomes given the same causal
attributes. Ragin (1999) suggests using probabilistic criteria to evaluate sufŽ ciency – to
guide decisions about rows with contradictory outcomes. For example, a researcher
might argue that if signiŽ cantly greater than 80 percent of the cases in a given row
display the outcome (using an alpha of 0.05), then the combination of conditions
speciŽ ed in the row is ‘almost always sufŽ cient’ for the outcome (see Ragin 2000).
For the purposes of this exposition, we allowed the software to assign outcomes to
unobserved cases in a way that produced the most ‘parsimonious’ solutions of truth
tables (Ragin 1999, 2000). Practical applications would require the researcher to
justify any such simplifying assumption in terms of theoretical or substantive
knowledge of the area. Although this is an aspect of QCA that could be developed, it
should be remembered that in almost all conventional quantitative analyses, a similar
problem occurs: many regions of the vector space formed by the independent variables
are devoid, or virtually devoid, of cases. In many research reports, the assumptions
used to deal with these voids (e.g. causal additivity and linearity) remain more or less
invisible to both researchers and their audiences.
502 Public Management Review

Notwithstanding these methodological issues, the substantive Ž ndings from our

application of QCA in a study of state-level barriers to policy diffusion indicate the
potential of QCA as a systematic approach to the identiŽ cation of linkages between
the causal factors that emerge as important to case study participants. If used to
supplement primary methods of qualitative analysis, QCA may provide a valuable tool
for public services research.

ACKNOWLEDGEMENTS

This research was funded by the Health Care Financing Administration (award
#500–97–002). The article re ects the opinions of the authors and not those of the
funding agency.

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