Speaking from Experience: Medicaid Consumers as Policy Storytellers

Abstract

Kentucky’s proposed Medicaid reforms, initiated in 2016 and blocked in federal court in 2018 and again in 2019, elicited an extraordinary volume of public input on the value of Medicaid (publicly-funded health insurance for low-income individuals). Personal statements from current and former Medicaid consumers, through written comments submitted to the Centers for Medicare and Medicaid Services, offer insights into the strategies employed by a segment of the public that contributes infrequently to policy debates. Through a combination of manual and automated content analysis of a random sample of 1100 public comments, we analyze the policy narratives of participants, examining how narrative and non-narrative elements varied depending on commenters’ relationship to Medicaid consumers. Nearly all comments met (and most exceeded) the threshold for a policy narrative, while relatively few comments drew on research-based content typically considered privileged in the rule-making process. Further, these narrative elements cohered in distinct storylines from current and past Medicaid consumers and from those who identified as service providers. This research underscores the importance of narratives as sources of evidence in regulatory processes and suggests that public comments are fertile ground for research using the Narrative Policy Framework. This work also illuminates bottom-up narrative construction, a process thus far overlooked in micro-level research presuming that citizens are passive recipients of narratives, rather than producers themselves. For future work examining micro-level narrative production, we identify important considerations, including the role of narrator trust, audience, forms of evidence, setting, and the interaction between the meso and micro levels.