Federalism by Waiver: MEDICAID and the Transformation of Long-term Care

In recent years, many states in the U.S. have substantiallyreinvented their Medicaid programs through the unprecedenteduse of federal waivers. This article focuses on 1915c programwaivers, which gave states the opportunity to overcome Medicaid'sinstitutional bias by offering more home and community-basedservices. The use of this tool has fueled deinstitutionalizationand other program changes. It reflects the rise of executivefederalism—the growing tendency for major program decisionsto shift from the legislative arena to the executive branchof the national and state governments. By functioning as licenses,the 1915c waivers take devolution via the administrative processto new levels. The proliferation of these waivers suggests aneed to revise prior conceptions of federal–state relations,such as picket fence federalism.