Shaping Health Policy for Low-Income Populations: An Assessment of Public Comments in a New Medicaid Waiver Process

Abstract

Since the Supreme Court decided that the Affordable Care Act's (ACA) Medicaid expansion is optional for the states, several have obtained federal approval to use Section 1115 waivers to expand Medicaid while changing its coverage and benefits design. There has long been concern that policy making for Medicaid populations may lack meaningful engagement with low-income constituents, and therefore the ACA established a new process under which the public can submit comments on pending Medicaid waiver applications. We analyzed 291 comment letters submitted to federal regulators pertaining to Medicaid Section 1115 waiver applications in the first five states to seek such waivers: Arkansas, Indiana, Iowa, Michigan, and Pennsylvania. We found that individual citizens, including those who identified as Medicaid-eligible, submitted a sizable majority of the comment letters. Comment letters tended to mention controversial provisions of the waivers and reflected the competing political rhetoric of "personal responsibility" versus "vulnerable populations." Despite the fact that the federal government seemed likely to approve the waiver applications, we found robust public engagement, reflecting the salience of the issue of Medicaid expansion under the ACA. Our findings are consistent with the argument that Medicaid is a program of growing centrality in US health politics.

A case study of the 1115 waiver using population health informatics to address disparities

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From the Margins to the Center: A Bottom-Up Approach to Welfare State Scholarship

“…Finally, we maintain that a bottom-up approach can improve political scientists' understanding of the politics of social policy by redirecting their attention towards overlooked arenas and forms of political conflict. Recent work in the legal field, for example, has noted how marginalized groups can leverage the notice and comment period of regulatory rulemaking to achieve political gains in the welfare state (Cortland and Tani 2019;Jarlenski et al 2017). Similarly, Michener (2019a) identifies the power that community organizers and their members have in shaping local welfare politics through grassroots movements to demand a right to civil counsel.…”

Political Science and U.S. Health Policy in the Era of the Affordable Care Act

“…The Obama administration, faced with recalcitrance by many states, short timetables, and limited federal implementation funds, became even more adamant to use these powers when the Supreme Court altered bargaining positions further by emasculating the Medicaid expansion, perhaps the most crucial part of the ACA (Banks, ; Haeder & Weimer, ; Richardson, ). Examples of this vast use of executive powers can be found in its use of section 1115 waiver (Jarlenski et al, ; Thompson, ; Weissert, Pollack, & Nathan, ) and rulemaking (Bagley, ; Haeder, Weimer, & Mukamel, ; Kersh, ). However, the Obama administration ultimately was unwilling to bargain away partial Medicaid expansions, Medicaid block granting, and Medicaid work requirements (Dinan, ).…”