When considering closed Medicaid formularies, researchers propose that state-based policymakers should factor in social values when implementing the changes and should incorporate deliberative procedures that include beneficiaries’ input, according to an article published in AMA Journal of Ethics.  

The relatively recent submissions by policymakers in Massachusetts and Arizona requesting to close their Medicaid formularies highlighted ethical concerns regarding access and treatment of patients who are poor or vulnerable. For instance, the Centers for Medicare and Medicaid Services denied Massachusetts’ request to close their formulary based on perennial ethical issues surrounding government program missions, rights to health and wellness for the poor, and the ramifications of denying sick beneficiaries access to therapeutic options solely on the basis of reducing healthcare costs. 

The researchers claim that to effectively deal with these ethical concerns, policymakers should address the underlying social concerns that surround the Medicaid program. The most major consideration is the social value exchange for Medicaid program savings due to a closed formulary (ie, savings for Medicaid might help bolster other state programs that affect health like early childhood education). However, juxtaposing saving money against saving lives requires a clear, transparent, and deliberative process.  

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The researchers highlighted that Norman Daniels “famously argued that the structure of the United States healthcare system makes saying no difficult to justify, because the savings from saying no to some patients could end up serving socially unproductive purposes.” They further note that Daniels’ idea of “accountability for reasonableness” is a more ethical and efficacious approach for policymakers in a complex ethical environment because it requires that reasoning for these decisions is made public and that the social value trade-offs are acceptable to those affected.

The researchers concluded that despite the likelihood of poorer patients being put at a disadvantage because of closed formularies, those arguments aren’t enough to reject closed formularies in government programs. They also stated that “there should be a minimum ethical requirement for justifying the reallocation of funds and that the formulary design should be guided by a procedural approach emphasizing deliberation, transparency, and engagement — do not dismiss the idea of closed formularies but rather suggest how they might be achievable in a socially just way.”


Rand L, Persad G. Are medicaid closed formularies unethical? AMA J Ethics. 2019;21(8):E654-660.