Document Type

Research Report

Publication Date



Provisions in the Medicaid statute permit states to apply for waivers from traditional program requirements. On January 16, 2009, the federal government approved Rhode Island's Global Consumer Choice Compact Waiver. In exchange for a cap on combined federal and state spending of $12.075 billion through 2013, Rhode Island received greater flexibility to adopt certain Medicaid program changes. This study analyzes the design and implementation of the Global Waiver to draw general lessons for health reform at the state-level, a key concern given ongoing state discretion to improve their health care systems under the Patient Protection and Affordable Care Act. Data derive from 325 archival sources and 26 semi-structured interviews. The Global Waiver would not have happened without political and ideological alignment between Rhode Island’s Republican Governor and the Bush administration and the fractured nature of the waiver’s opposition across provider and advocacy groups. The waiver was motivated largely by ongoing fiscal and programmatic pressures. Development was dominated by state officials, working over a short time period characterized by growing budgetary uncertainty. Dissatisfaction in the level of outside input contributed to distrust among stakeholder groups. Subsequent legislative constraints together with insufficient administrative personnel and antiquated information systems hampered implementation. So too did remaining divisions among those overseeing, advocating, and serving different beneficiary communities. Specific lessons include: ensuring sufficient levels of stakeholder input and transparency throughout the program design, approval, and implementation process; devoting adequate personnel and informational resources to program administration, including coordination across disparate elements of the state bureaucracy; and carefully considering the breadth and timing of the reform strategy pursued; factors that promote adoption, for example, may, in turn, impede implementation.


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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