Seven states have used Section 1115 waivers to expand Medicaid as part of the Affordable Care Act (ACA). While each state pursued a unique plan, there are similarities in the types of changes each state desired to make. Equally important to how a state modified their Medicaid programs is how a state talked about Medicaid and reform. We investigate whether the rhetoric that emerged in waiver states is unique, analyze whether the rhetoric is associated with particular waiver reforms, and consider the implications of our findings for the future of Medicaid policy making. We find that proponents in waiver states have convinced a conservative legislature that their reform is sufficiently innovative that they are not doing a Medicaid expansion, and not building on the traditional Medicaid program. Particularly striking is that none of these reforms are entirely new to the Medicaid program. While not new, the way in which waiver states have been allowed to implement many of the reforms is new and has become stricter. We find an emerging consensus utilized by conservative policy makers in framing the Medicaid expansion. Expansion efforts by conservative policy makers in other states have subsequently pushed this framing far to the right.
Three major principles were embedded in the Affordable Care Act (ACA) when it passed in 2010: (1) federalism and encouraging state-level innovation; (2) universal coverage; and (3) incentives to bend the cost curve through delivery model innovations. When the Supreme Court ruled on the constitutionality of the ACA in 2012, upholding the individual mandate but allowing states the option to expand Medicaid, the Court consequentially privileged the first principle over the second (with no comment or action on the third). Allowing states the option to expand coverage necessarily means universal coverage is no guarantee.1 By the end of 2015, nearly 33 million people remained uninsured, primarily those residing in the nineteen non-expansion states (KFF 2016b). Although the decision to expand is largely driven by party control in the states, some Republican governors in conservative states have been able to pass their own version of a Medicaid expansion through the use of waivers. Indeed, Republican governors and legislators have used the first principle—federalism and states’ rights—to claim that they have expanded coverage to low-income families, thereby allowing them to pull down substantial federal funds, but have taken a path uniquely suited to their state’s conservative values.
– Journal of Health Politics, Police and Law
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