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

In recent years, many states in the U.S. have substantially reinvented their Medicaid programs through the unprecedented use of federal waivers. This article focuses on 1915c program waivers, which gave states the opportunity to overcome Medicaid's institutional bias by offering more home and community-based services. The use of this tool has fueled deinstitutionalization and other program changes. It reflects the rise of executive federalism—the growing tendency for major program decisions to shift from the legislative arena to the executive branch of the national and state governments. By functioning as licenses, the 1915c waivers take devolution via the administrative process to new levels. The proliferation of these waivers suggests a need to revise prior conceptions of federal–state relations, such as picket fence federalism.