Adam S. Wilk, PhD, assistant professor of Health Policy and Management at Emory University's Rollins School of Public Health, recently published an article in the Journal of Health Politics, Policy and Law that explores state policy makers' decisions in 2014 on a time-limited aspect of the Affordable Care Act (ACA) that provided increased fees for primary care services in Medicaid. 

Wilk and his colleagues specifically focused on what appeared to be a paradox—several states continued this "fee bump" provision (which increased payments to primary care physicians caring for Medicaid patients), with the goal of improving Medicaid beneficiaries' access to care, yet chose not to implement Medicaid expansion under the ACA. 

Using qualitative interviews and a limited quantitative analysis, the researchers worked to determine why states made these apparently contradictory decisions, which seem all the more perplexing when observing that virtually all financial projections showed that the Medicaid expansion was a net financial win for states, while an extended fee bump would involve significant state expenditures. So, why not opt to do both, or at least the former rather than the latter? 

"Our most interesting finding was that while Medicaid expansion efforts in these states were sunk due to general antipathy toward the ACA, the states we examined were able to extend the fee bump by disassociating it from the ACA," says Wilk. In other words, avoiding talk of the ACA made these advocacy efforts more effective.

The researchers also saw that states had varying processes for updating their Medicaid fees from year to year. Those states with more closed processes involving fewer stakeholders tended to be more successful in pushing the fee bump through because they could do so quietly.

"Many of the people we talked to said the biggest reason they pursued this fee bump extension was that they wanted to do something for the disadvantaged populations in their state," says Wilk. "If they couldn't expand Medicaid, one thing they could do was extend the fee bump, which would maintain or improve their constituents' access to care. Some suggested it might also be a sort of 'make good' for health care providers in their states who treated Medicaid patients and were disappointed that the Medicaid expansion didn't pass."

As Wilk and his co-authors mention in the article, similar tactics could be employed during the Trump administration as policy makers tackle additional Medicaid and ACA-related legislation, or other policies associated with unpopular laws or an unpopular administration. 

Wilk will be presenting the findings outlined in this article at the Association for Public Policy Analysis and Management Conference, held November 2-4, 2017, in Chicago.

Related Reading:

• Uncertainty Disrupts More than State Marketplaces by Adam S. Wilk