Deliberative Bioethics to Inform Policy Surrounding the Medicaid Sterilization Waiting Period

This ongoing project is a supplement to the primary R01 in collaboration with the University of Michigan and our community partners.

Abstract

The bioethical considerations of the 30-day waiting period in the Medicaid sterilization policy are complex. On one hand, policies that constitute a potential barrier to autonomously-desired care only for one patient population (Medicaid enrollees) are unfair. On the other hand, the 30-day waiting period was instituted in response to a history of coerced sterilizations in women of color and low socioeconomic status. Today, structural racism, implicit bias, and social determinants of health factors continue to produce disparities in maternal health. Patients impacted by the Medicaid policy have noted that while the 30-day waiting period was not necessary for them in making the decision for sterilization, they felt the waiting period was important to protect other patients against coercion. Thus, there is a need to revisit the policies for sterilization to ensure that they fulfill tenets of reproductive justice, though questions remain as to how women covered by Medicaid, like those with other insurance, might have their autonomous decisions for sterilization respected, while also ensuring freedom from coercion or undue pressure. In seeking a collective solution to a challenging policy question, our community-academic partnership will engage those most affected by the policy.

The overall objective of this proposal is to employ deliberative bioethics methods to better understand the goals and priorities of patients themselves regarding revision of the 30-day Medicaid sterilization waiting period. Our central premise is that policy decisions for post-partum sterilization that are reached by participants in informed deliberations will be acceptable to those most affected by those policies – low-income women and couples.

Specific Aims

Aligned with the scope & strategy of the parent grant, we will further our central premise via two specific aims:

1. Engage patients and couples with Medicaid insurance in informed deliberations about the 30-day Medicaid sterilization waiting period. Long-standing, diverse community-academic partnerships in Michigan have experience with deliberative methods and with evaluating Medicaid policy. We will conduct deliberation exercises with 10 groups of 9-15 persons, including groups of Medicaid current and potential enrollees who have experienced pregnancy and some that include couples. This deliberative approach will allow for future policy revisions to account for the viewpoints of patients themselves, with a balance between autonomy and protection from coercion that fits the needs of the people and population impacted.
2. Prepare preliminary policy briefs that describe the views of patients as the stakeholders in potential Medicaid sterilization policy revision. We will analyze the existing evidence base in light of Aim 1 results in order to prepare preliminary materials for dissemination. Such preliminary policy briefs will set the stage for future, broader community-based participatory research and deliberative bioethics work in other states with distinct reproductive health policies, as well as for eventual federal health policy change.

This project is funded through the National Institute of Health’s NICHD R01 HD098127 as a supplement through the bioethics mechanism of the NIH Office of Science Policy (OSP) within the Office of the Director (OD).