Medicaid is the largest grant-in-aid program in the United States. Reform in this area, therefore, provides a unique opportunity to study the intersection between federal and state policy making in an area recently characterized by substantial uncertainty deriving from the lingering effects of the Great Recession, ongoing debate over the federal budget, and implementation of the Patient Protection and Affordable Care Act. Invariably states reform the way health care is delivered, regulated, and financed within broader parameters established by federal statutes and regulations. It is critical therefore that effective strategies be put into place if both current and future health and long-term care reform efforts are to have their greatest chances at success. Rhode Island is the first state to receive permission to operate its entire Medicaid program under a global cap. As a consequence, it has entered the national consciousness as a key data point potentially supporting the block grant approach to Medicaid reform.
In this book, Edward Alan Miller identifies factors that either facilitated or impeded the design and implementation of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver in order to draw broader lessons for the Medicaid block grant debate and health and long-term care reform more generally. Evidence gathered from archival sources and in-depth interviews with key stakeholders exposes the role that provider capacity has played in the implementation process, including adult day care, assisted living, home maker, and other home- and community-based services. The impact of the Global Waiver on the nursing home sector is examined as well, in addition to new authority to obtain federal matching dollars for previously state-only funded programs.
By providing a sophisticated understanding of factors enhancing or impeding state health reform, this book will contribute to improvements in the development and administration of policy development at both the state- and federal-levels.
"This is a wonderful in-depth case study of Rhode Island's Medicaid Waiver debate. Every few years the debate about block granting Medicaid remerges. It is only with details found within that we can enter into those debates with a clear idea of its implications. We should thank Miller for such an insightful analysis."
—Colleen Grogan, University of Chicago
"In this book, one of the nation’s foremost experts on Medicaid and state health policy dissects the challenging process of translating a bold idea into a workable new system of care for Rhode Island’s most vulnerable citizens. It delivers bad news for those who would reflexively put all states on fixed block grants for their Medicaid programs. It reminds reformers of all persuasions of how important leadership, expertise, and outreach to community stakeholders are to producing even modest improvements in vital services and system efficiency."
—Tom Oliver, University of Wisconsin-Madison
"This book is an important addition to the literature on Medicaid, implementation, and federalism. The book reminds us that management matters: programs like Medicaid work best when leadership is strong and clear, there are long-standing and effective public bureaucracies and adequate data systems, and meaningful efforts are made to ensure adequate consumer and provider input."
— Michael S. Sparer, Columbia University
1. Rhode Island as Policy Laboratory 2. Waiver Genesis 3. The Politics of Approval 4. A Primer on the Global Waiver 5. External Factors and Implentation 6. Internal Factors and Implentation 7. Service Delivery and Implentation 8. Waiver Achievements and Lessons 9. Block Grants and Retrenchment