One of the key strengths of the Medicaid program is its built-in capacity for variation and innovation. Within broad parameters, each state agency can make different decisions about how to implement state plan requirements, take up state options, or utilize various waiver authorities to construct their program. If states want to move beyond those parameters, they can seek federal approval through section 1115 demonstration waivers after consultation with their stakeholders. Negotiations between the federal and state governments concerning such waivers, even when pursuing shared goals, are complex and time-consuming, involving tests of budget neutrality and establishment of terms and conditions including evaluations. Nonetheless, more than 45 states now operate such waivers enabling states to test and adopt new ideas to improve coverage, access, quality, and outcomes.[1]