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14 INTRODUCTION only improve access and quality but also control costs by contracting with HMOs to better manage and monitor the care recipients receive. Other state Medicaid reform plans include explicit restrictions on the benefit package. Florida’s recent Medicaid reform legislation provides an example of this approach. Such benefit restriction approaches are in line with provisions passed under the federal Deficit Reduction Act (DRA) of 2005 in which states were given more flexibility regarding Medicaid benefits and cost sharing, including providing benchmark coverage to certain populations rather than full Medicaid benefits. With this increased flexibility, under DRA, come difficult decisions about how to set limits and for whom. The important commonality among all Medicaid reform efforts is the acknowledgment that explicit trade-offs must be made. Do we expand eligibility to Medicaid coverage or expand access to more providers for those who already have coverage? If we expand coverage , to whom? Should the state move toward universal coverage, as Massachusetts is currently attempting? If so, how should the state control expenditures under such an expansion? Should the state contract with private insurers, as they did under Medicaid managed care? Should the state cover more people but restrict benefits? States have to answer these questions, but they will make trade-offs in very different ways. Clearly there is no magic formula for states to follow . These are questions that only our fundamental values can help us answer, which is why the questions of who decides and how are so paramount. Indeed, because these health policy questions, especially those having to do with benefit coverage and provider reimbursement, are so ethically difficult and can be technically complex, many states seek answers to these questions by creating advisory boards (or councils) where diverse points of view are allowed to be heard, discussed, and debated. In looking at all the state’s Medicaid websites , we were able to identify some type of an advisory board or Medicaid commission in every state. Participation on Connecticut’s advisory board and various subcommittees included representatives from the following invested stakeholder groups: Medicaid consumers , Medicaid advocates, Medicaid providers, representatives from participating HMOs, representatives from various state agencies, and members or staff from the state legislature. Because the structure of Medicaid managed care (the contracting approach with HMOs) is essentially the same across the states, the central stakeholder groups THE PROBLEM AND PUZZLE OF PUBLIC SILENCE 15 are the same, and are similarly represented on state Medicaid advisory boards. Moreover, the central purpose presented on state Medicaid advisory board websites is similar: to encourage discussion and deliberation of interested groups’ concerns, questions, and ideas about the state’s Medicaid managed care reform. Although the federal government requires (under 42 CFR 431.12) that states have an advisory committee to the Medicaid agency director , most states have gone beyond this requirement and have independently set up advisory boards and Medicaid reform commissions . For example, when Florida recently passed legislation (Senate Bill [SB] 838) to implement a pilot test of a “defined contribution ” plan, they also mandated the creation of an advisory board to oversee the design and implementation decisions associated with this controversial plan. Similarly, Missouri created the Medicaid Reform Commission to help the state decide how to control Medicaid costs. And Ohio setup both the Commission to Reform Medicaid and the Medicaid Administrative Study Council.8 In other words, as in Connecticut, these advisory boards are not just token boards set up in response to a federal requirement but boards that emerge out of pressure within states to broaden participation in the decisionmaking process. In sum, although our case study examines the deliberation of one state’s advisory board during 1995–96, the goals for the Medicaid reform in Connecticut and the trade-offs the state needed to consider—control costs, improve access and quality—are as relevant today across the states as they were then in Connecticut. In other words, there is nothing about the Connecticut case that makes it atypical in terms of its advisory board or the central concerns of its Medicaid reform. METHODS To examine what participants in the advisory board process said in public discussion and chose not to say, and why, we employed a two-pronged approach. In particular, we used a participant observation method to track what topics were discussed and how and inperson interviews with all participants in the process to understand what topics participants cared about. Before detailing the...

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