Challenges of Health Care Devolution: Problems of Legitimacy, Consumer Knowledge, and Work Transfer in Kansas Medicaid

Abstract

The current study is an exploration of Medicaid reform in Kansas, entitled ‘KanCare,’ It address three research questions. (1) What is KanCare and how was it enacted despite the contentious politics around it? (2) How has KanCare affected consumers, or the beneficiaries of Medicaid? (3) How has KanCare affected the provision of health care in Kansas for KanCare consumers? Analysis of interviews with KanCare consumers, health care providers, and policymakers, documents that gave voice to state officials and one consumer advocacy organization, Kansas Health Consumer Coalition, and participant observation revealed three major themes. First, KanCare entailed a contentious legitimation process between its proponents and critics along the issues of a need for change, accountability, and success. By shaping the discourse, advocates helped secure mechanisms of public responsibility that could have a policy feedback effect of further democratizing health policy in Kansas. Second, disparities in consumers’ knowledge of KanCare in relation to the states effort to get the word out about KanCare revealed limitations of the consumer choice model. Third, despite limitations, consumers employed strategies to meet their health needs, while providers did more work to help their patients. Glazer’s term ‘work transfer,’ or a shift in responsibility and effort from paid to unpaid labor, characterizes consumers’ and providers’ stories. There are four theoretical implications of the dissertation. The research contributes to the stress process model of health by advancing personal agency as a factor in mitigating stress due to poverty. It sheds light on how Medicaid consumers make health decisions. The study offers insights into how managed care impacts costs, health outcomes and quality of care by shifting effort to providers. The dissertation uses framing theory and the political process model to understand how advocacy organizations influence policy. Policy recommendations are made and limitations of the study and suggestions for future research are discussed.