Rescaling Behavioral Health: Medicaid Redesign and Contested Rural Practices

Background and Purpose: Recent studies in anthropology draw attention to scale-making practices that define who is larger or smaller, inside or outside, central or marginal (Carr & Lempert 2016). Institutional scholarship, for instance, relies on scale when it theorizes organizations as units nested within surrounding task environments. But there are many ways to imagine and institutionalize the scalar distinction between organization and environment. Ethnographic methods provide a set of tools for examining the effects of scalar practices as they sort and order institutions. This paper employs ethnography to analyze how scale was activated and contested as New York State overhauled its behavioral health payment and delivery system. It asks two questions. How did Medicaid remake the scale of behavioral health governance? And what kinds of institutional responses and struggles did it produce? I investigate the active contests that emerged in response to Medicaid redesign, and weigh its implications for behavioral health organizations that provide services to socially and economically vulnerable individuals.

Methods: Ethnographic data were collected from 2014 to 2018. I used methods of direct observation, interviewing, and document analysis to track the development of New York State’s Regional Planning Consortiums (RPCs). RPCs were designed to oversee the state’s transition to managed care and ensure that local stakeholders had influence over the implementation of behavioral health reforms. In total, I conducted over 220 hours of direct observation and 86 semi-structured interviews. I used NVivo qualitative software to manage data, and grounded theory techniques to analyze data.

Results: Medicaid redesign produced two competing scalar logics: 1) Public officials, consultants, and technical assistants advanced centralization with the aim of eliminating regulatory silos and integrating care. They promoted privatization and standardization as a means to rescale risk and transform services units. 2) County planners, providers, and consumers struggled against Medicaid centralization, arguing that “rural” areas were poorly suited to accommodate the interests of “Albany.” They issued a counter-scale of rurality, arguing that public reforms did not recognize or accommodate the unique demographic and cultural composition of rural areas. Thus, these stakeholders contended that the scalar dimensions of reform threatened the mission and existence of rural services, and would negatively impact behavioral health outcomes for poor and marginalized individuals.

Conclusions and Implications: This study examines the shifting boundaries between organizations and environments. It finds that politics are advanced through scale-making practices that remake the policy environment. Stakeholders’ struggle to define and establish a counter-scale demonstrates how organizations oppose the constructed policy environment and reassemble scale in an effort to wrest back control. This contest reveals perceived sources of threat in Medicaid redesign, with especially negative implications for provider organizations and consumers who identify their interests as rural.