JLARC itself initiated this study in order to gain a more comprehensive view of Medicaid in Washington.  JLARC’s recent performance audits of the Mental Health and Developmental Disabilities Divisions within the Department of Social and Health Services (DSHS) highlighted the dominant role of Medicaid, and federal requirements, in setting the policy directions and operations of this state agency.  This report takes that comprehensive perspective to examine the range of Medicaid’s involvement in Washington’s overall biennial budget and, especially, Medicaid’s dominance over the budget and policy decisions in DSHS.  Programs, policies, federal directives, client populations, and management issues are surveyed and reviewed.  This report also discusses initiatives to improve the coordination of services and resources to persons receiving Medicaid-funded services.  JLARC makes five recommendations to: strengthen the oversight of the decentralized management of the program; improve key data systems to support a comprehensive view of the program; extend a comprehensive view of the program to its fiscal management by rigorously reviewing approximately $5 billion in biennial Medicaid expenditures for cost containment opportunities; and assess the best techniques for understanding future caseload patterns.