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With the election of Donald Trump and unified control over Congress, Republicans are poised to reshape health policy in the United States. Although attempts to "repeal and replace" the Affordable Care Act (ACA) have exposed rifts within the Republican party, one target of reform with broad appeal among Republicans is Medicaid, which provides health insurance for low-income and disabled Americans. Congressional Republicans and Trump's selections to lead the Department of Health and Human Services and the Centers for Medicare & Medicaid Services, Tom Price and Seema Verma, respectively, have proposed capping the amount of federal support for Medicaid, leading states to seek creative solutions for cost savings. One potential solution to future budget constraints is using consumer-directed principles to craftMedicaid programs.1
The phrase "consumer directed" has been used in health care to suggest a variety of policy mechanisms. Consumer-directed principles have traditionally been framed as a means to incentivize higher-quality health decisions2 and to provide flexibility and choice for patients. In the context of Medicaid reforms, consumerdirected principles-defined here as premiums, cost sharing (e.g., deductibles, coinsurance, and copayments), health savings accounts, and healthy behavior incentive programs-now signify that patients take on greater financial burden and clinical decision-making. Consumer-directed principles in Medicaid incentivize desired behaviors among low-income patients with great financial stakes. Advocates of these principles contend that they encourage patient awareness of costs and decision-making through the creation of financial and behavioral incentives.
Such policies align with Republican ideals of personal responsibility and reliance on free-market principles. However, evaluations of the effectiveness of consumer-directed principles have highlighted the potential shortcomings of these components. 3Herewe highlight a shiftin the spread and use of these principles inMedicaid that the Trump administration is likely to push even further, with concerning potential effects on the most vulnerable.
To evaluate how states have incorporated consumer-directed principles within Medicaid programs, we performed an analysis of Medicaid state plans, amendments, and waiver applications within three Medicaid populations-Section 1931, ACA Medicaid expansion, and Section 1115 expansion states- highlighting changes in the use of these Medicaid principles over time (Table 1). Section 1931 of the Social Security Act was part of the welfare reform legislation signed by Bill Clinton in 1996, creating a new category of eligibility for low-income...