Major Medicaid reforms initiated in Arizona, California, and New York in the 1980s form the foundation of this study, which explores issues to consider when implementing change in state Medicaid programs. We prepared case studies of these reforms, describing the innovations and assessing the implementation process in each state. These case studies are used to illustrate broad issues and processes of Medicaid reform. Six lessons emerge from our analysis: (1) Expect reform models to change over time; (2) strive for predictability and continuity in the reform; (3) encourage behavior changes through the use of incentives; (4) use special administrative or political channels to simplify the reform; (5) expect reform models to converge over time; and (6) implementation difficulties can be predicted. These lessons should educate decision makers about how to implement possible future solutions to problems like those seen in Medicaid programs at the start of this decade.

It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system. For the initiator has the enmity of all who would profit by the preservation of the old institutions and merely lukewarm defenders in those who would gain by new ones.

Machiavelli, The Prince

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