The Medicaid Evolution: The Political Economy of Medicaid Federalism is a policy analysis of the largest health financing initiative in the United States, as well as the largest federal grant program to the states. Concentrating on the bargains that shaped Medicaid federalism over its more than 40-year history, the evaluation extends back to the New Deal Era and the institutional roots of the Social Security Act. Public Policy is bargaining. And no area of Public Policy is shaped more by conflict resolution than Federalism. The publication concentrates on particular “moments in time” or “punctuations” when Medicaid financing and its administrative structure were prioritized on the national agenda. It then “unpacks” these negotiations. This Medicaid review is inevitably intertwined with the most profound attempts at national health reform in our country’s history.

The writing is comprised of four parts: Part I: Policy and Federalism Theory; Part II: Medicaid in Retrospective; Part III: The Modern Era; and Part IV: Summary and Conclusions. In its two chapters, the first part establishes, first, the theoretic framework of Institutional Economics and a compilation of political science theories, and, second, a meta-analysis of federalism theory. Part II, Chapters 3 to 6, moves through the Pre-Medicaid Enactment Era, the LBJ Rights Era, the Watershed Era of President Nixon’s Administration, and the Budget Era of the Reagan years. Part III focuses on “The Modern Era,” defined as 1992 through 2007. Chapters 7 through 11 are informed by dozens of interviews with the most prolific experts and pivotal decision makers in Medicaid. Part III reviews President Clinton’s Waiver Presidency and the pre-eminence of The Administration State during the G.W. Bush Administration. Part IV, Chapter 12, provides Summary and Conclusions.

In addition to the interviews, the primary research includes archival review of several collections at The Lyndon Baines Johnson Presidential Library, The Center for Legislative Archives (NARA) in Washington, D.C., and extensive research at the Law Library of The Library of Congress and the National Library of Medicine . It builds on substantial periodical and newspaper review, including forty years of Congressional history. Hundreds of secondary sources also inform this work.