Abstract

Objective: Medicaid is the primary payer of long term services and supports in the United States. It is administered by the states and jointly funded by the states and federal government. Provisions in the Medicaid statute permit states to apply for waivers from traditional program requirements. This project analyzes the design and implementation of the State of Rhode Island's Global Consumer Choice Compact Waiver, which was approved by the federal government on January 16, 2009. In exchange for a cap on combined federal and state spending of $12.4 billion through 2013, Rhode Island received greater administrative flexibility and the ability to receive federal matching funds for populations and services previously covered only by the State. A primary goal was to facilitate state efforts to shift the provision of care for elderly and disabled beneficiaries to the lowest levels possible.

Methods: Semi-structured interviews were undertaken with subjects chosen through a combination of purposive and snowball sampling. This included 26 interviews with 30 state administrators, elected officials, consumer advocates, and provider representatives. Transcripts were coded to identify recurring themes and patterns in responses. Review of pertinent archival resources took place as well.

Results: Findings suggest that the Global Waiver had its antecedents in previous efforts to reform Rhode Island’s Medicaid program and that it was motivated largely by on going fiscal and programmatic pressures to restrain Medicaid spending. By enabling state officials to draw in additional federal funding for costs not previously matched by the federal government, the Global Waiver provided a mechanism for continuing and, possibly, expanding funding for populations and services that might have otherwise been vulnerable to state fiscal cutbacks. Development of the waiver was dominated by state officials, working over a short time period characterized by growing fiscal uncertainty. This generated dissatisfaction in the level of outside input, thereby contributing to distrust on the part of other stakeholder groups, including state legislators, providers, and beneficiary representatives. Resulting constraints imposed by the state legislature together with insufficient numbers of state administrative personnel and the use of antiquated information systems hampered implementation. So too did a lack of cooperation among those overseeing, advocating, and serving different beneficiary communities, including the elderly, physically and developmentally disabled, mentally ill, and children/families.

Policy Implications: Some argue that Medicaid should be converted to a block grant whereby the federal government reduces its fiscal contributions in exchange for granting states greater flexibility over program administration. Rhode Island’s Global Waiver has been held up as a successful example of the block grant strategy. The Global Waiver, however, was not a block grant but a caped federal match. Furthermore, widespread concern about the cap proved unwarranted; the primary factor limiting Medicaid program growth was state appropriations and spending. While the intention was to increase state discretion, challenges deriving from the way the program was designed and implemented resulted in combined levels of federal and state legislative oversight that proved greater for program administrators than if the waiver had not been pursued.

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