Intergovernmental Negotiation in Medicaid: Arkansas and the Premium Assistance Waiver

Negotiations between federal and state officials are a mainstay of intergovernmental relations, but the politics of negotiation have been largely understudied. In this article, we provide a window on those politics by examining the development of the Arkansas premium assistance waiver—an early and influential Medicaid waiver. We examine the leverage of both the federal and state governments in their efforts to reach agreement on a plan that suited both sets of actors. The federal government was providing funding important to the state, but the state had the capacity necessary to put a program in place. The federal government wanted some type of expansion in a Southern state; Arkansas wanted to do it “their way.” Also key to the Arkansas case is the persistence and shared vision of the federal and state actors who in the end trusted each other and produced a policy both were proud of.