How Would Low-Income Communities Prioritize Medicaid Spending?

Abstract

Context: Medicaid plays a critical role in low-income, minority, and medically underserved communities, particularly in states that have expanded Medicaid under the Affordable Care Act. Yet, the voices of underresourced communities are often unheard in decisions about how to allocate Medicaid's scarce resources, and traditional methods of public engagement are poorly suited to gathering such input. We argue that deliberative public engagement can be a useful tool for involving communities in setting Medicaid priorities. Method: We engaged 209 residents of low-income, medically underserved Michigan communities in discussions about Medicaid spending priorities using an exercise in informed deliberation: CHAT (CHoosing All Together). Participants learned about Medicaid, deliberated in small groups, and set priorities both individually and collectively. Findings: Participants prioritized broad eligibility consistent with the ACA expansion, accepted some cost sharing, and prioritized spending in areas—including mental health—that are historically underfunded. Participants allocated less funding beyond benefit coverage, such as spending on healthy communities. Participants perceived the deliberative process as fair and informative, and they supported using it in the policy-making process. Conclusion: The choices of participants from low-income, medically underserved communities reflect a unique set of priorities and suggest that engaging low-income communities more deeply in Medicaid policy making might result in different prioritization decisions.

Evaluating community deliberations about health research priorities

“…16 It has been used to examine healthcare priorities in a number of different settings in the USA and other countries, engaging a wide range of individuals and communities. 15,[17][18][19][20][21][22][23][24] A number of studies have concluded, in these settings, that CHAT facilitates high-quality deliberation, changes individual preferences and opinions and increases knowledge. 15,18,20 There is some evidence that CHAT leads participants to take a more public-spirited view of resource allocation decisions; for example, a 2004 study found that participants in CHAT were willing to give up some benefit coverage to increase coverage of the uninsured.…”

“…† CHAT was originally developed as a “serious game” for deliberations about the design of health insurance plans that aims to promote informed, reasoned dialogue about allocation decisions among ordinary persons . It has been used to examine health‐care priorities in a number of different settings in the USA and other countries, engaging a wide range of individuals and communities . A number of studies have concluded, in these settings, that CHAT facilitates high‐quality deliberation, changes individual preferences and opinions and increases knowledge .…”

Engaging Consumers in Medicaid Program Design: Strategies from the States

“…A broader body of work has examined the effects of structured public deliberation on policymaking, 39 finding that such engagement, compared with other methods like surveys, increased consumers’ knowledge of policy topics 9 and produced more valid and valuable results to incorporate into policy decisions 6 . Myers and colleagues used a public deliberation process to evaluate how low‐income communities prioritized Medicaid spending in Michigan, showing that the participants advanced a set of spending priorities unique to what had been historically funded 10 . While we found examples of these deliberative processes in some states—in the form of longitudinal committees and advisory groups dedicated to consumer education, discussion, and recommendations—such deeper engagement efforts remained the exception, not the norm.…”

“…That is, members of affected communities often know their specific needs and circumstances, thereby allowing policies to take into account knowledge that outsiders do not have 5 . In addition, research has shown tangible benefits to public engagement: policy decisions that incorporate input may better navigate and manage value conflicts as they arise, 2 increase knowledge, 6,7 build public trust, 8 and be viewed by the public as more legitimate 9,10,11 …”

“… 5 In addition, research has shown tangible benefits to public engagement: policy decisions that incorporate input may better navigate and manage value conflicts as they arise, 2 increase knowledge, 6 , 7 build public trust, 8 and be viewed by the public as more legitimate. 9 , 10 , 11 …”