Opting to opt-in: policy choice, program expectations and results in West Virginia's Medicaid reform initiative

Following the passage of the Federal Deficit Reduction Act in 2005, a few states, including West Virginia, redesigned their Medicaid programs to emphasize personal responsibility and consumer-driven health decisions. The West Virginia program was implemented in 2006 and was subsequently abandoned in 2010 due to changes in Federal laws and continuing criticism by advocacy groups whose expectations for enrollment in a wellness-based plan were not met. Using the results of a survey of the West Virginia members, the authors explore the public policy and implementation factors of this program. We argue that initial policy design relied on existing implementation mechanisms, while it needed specific tactics to address the novelty of the choice members were facing. With the passage of the Patient Protection and Affordable Care Act, the West Virginia results provide valuable insights for future health reform policy implementation, especially as they relate to consumer-directed health decision-making and the role of intermediaries who can play a role in assisting consumers in their choices.