Fulfilling States’ Duty to Evaluate Medicaid Waivers

Medicaid waivers have been a principal tool of innovation in health policy in the US since at least the mid 1970s. As Republicans seek to give the states more flexibility in their implementation and management of both Medicaid and the Affordable Care Act or its replacement, waiver authority is likely to be one of the key work arounds for avoiding political barriers in the US Senate. While block-granting Medicaid may require 60 senate votes, waiver authority already exists in both Medicaid law and the Affordable Care Act. Waivers also have great potential for application in other federal nations. Yet there is no theory to explain the way the application and review process evolves or the factors likely to shape the outcome. After a discussion of the theoretical underpinnings of what we call ‘negotiated federalism’, we apply it to examples of Medicaid waivers to see if the theory’s key elements – politics, party congruence, leverage, credit taking and experience – offer a useful perspective on this federal–state interaction so important to health policy.

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Medicaid Waiver Adoption for Youth With Complex Behavioral Health Care Needs: An Analysis of State Decision-Making

Journal of Disability Policy Studies ◽

10.1177/1044207319897058 ◽

2020 ◽

Vol 31 (2) ◽

pp. 87-98 ◽

Cited By ~ 1

Author(s):

Genevieve Graaf ◽

Lonnie Snowden

Keyword(s):

Mental Health ◽

Decision Making ◽

Behavioral Health Care ◽

State Mental Health ◽

Children And Families ◽

Care Needs ◽

Potential Cost ◽

Community Based ◽

Medicaid Waivers ◽

State Mental

Many states have enacted Home- and Community-Based Services (HCBS) Medicaid waivers, which waive or expand Medicaid means tests to increase access to community-based public mental health services for youth with Serious Emotional Disturbance (SED). This study sought to understand key factors in State Mental Health Authorities and Medicaid Agency decision-making in adopting Medicaid waivers for youth with SED. Using purposive sampling to collect data through semi-structured interviews with officials from 37 state mental health systems, interviews focused on fiscal, historical, and political reasons for states’ adoption or rejection of Medicaid waivers to serve youth with SED. Results suggest that decisions around waiver adoption relate to the size and flexibility of state budgets, the sufficiency of existing public HCBS funding and services, political prioritization of children and families, states’ desire to move away from a reliance on residential care, and ideology related to the role of the state in providing for the welfare of children and families. Advocacy efforts promoting state waiver adoption can address apprehensions about budget constraints and providing financial assistance to non-poor families by emphasizing potential cost savings from residential diversion and ethical imperatives to keep children in their homes and communities.

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