Document Type

Research Report

Publication Date



On January 16, 2009, the Federal government approved Rhode Island’s application for a Global Consumer Choice Compact Medicaid Waiver whereby the state became the first granted permission to operate its entire Medicaid program under the state plan and a single 1115 “research and demonstration” waiver. The Global Waiver has been implemented in the context of Republican proposals to turn Medicaid into a block grant which would give states substantially more flexibility administering the program in exchange for receiving an upfront allotment from the Federal government. Proponents have held up the Global Waiver as a successful example of what might be achieved nationally if all states received block grants to run their Medicaid programs. This study draws lessons from Rhode Island’s Global Waiver for the Medicaid block grant debate. Data derive from 325 archival sources and 26 semi-structured interviews. Results indicate that the Global Waiver is not a block grant but a capped federal match where the state is required to spend its own money before receiving the federal contribution. Moreover, the state did not receive unlimited discretion to administer Medicaid under the Global Waiver nor achieved nearly as much savings as has been claimed. Indeed, most savings obtained by Rhode Island during this time period derive not from efficiencies stemming from the Global Waiver but from increased federal spending and from measures the state could have implemented independently of the waiver. The generosity of the Global Waiver is in marked contrast to most block grant proposals which would substantially reduce the level of federal fiscal support. In the near future, turning Medicaid into a block grant is not going to occur in light of President Obama’s reelection. Identifying the implications of RI’s experience for Medicaid retrenchment and the block grant debate is important, however, as some states eschew expanding the program under the Affordable Care Act and as proponents continue to propose block grant approach to Medicaid reform, both in future budget proposals and presidential party platforms.


Funding for this study was provided by the Robert Wood Johnson Foundation (grant #64214). The authors would like to acknowledge Corina Ronneberg and Emily Gadbois for excellent support. There are no conflicts of interest and disclosures to report.



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