Health insurance coverage for the American poor is rooted in the federal system, thereby affording states considerable authority over its particular characteristics. Indeed, Medicaid is a jumble of fifty separate plans that are simultaneously governed by a variety of national directives and regulations. Costs have grown significantly over the decades, outpacing other state obligations and consuming an ever-increasing percentage of their budgets. In reaction, governors have sought — and achieved — more control over their low-income health plans, especially through waivers.

Christina Juris Bennett's story focuses on the unique statewide section 1115 waiver, TennCare, approved by the US Department of Health and Human Services in 1993. The goal was to increase the percentage of insured households in Tennessee while reducing the growth of Medicaid cost increases through statewide implementation of managed care. However, the experiment was disappointing: the state proved better at...

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