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Medicaid's transformation since its inception rivals the biological changes of metamorphosis, and this process is not yet over. Past metamorphoses include the change from a small program with eligibility linked to the states’ cash welfare benefits to one with national eligibility standards covering many not receiving cash benefits; from a traditional fee-for-service payment program to one dominated by capitated managed care arrangements; and, under the Patient Protection and Affordable Care Act of 2010, to a widely accepted component of a national system for near-universal insurance coverage. An analysis of the forces behind these significant changes suggests that future transformations are likely. Four potential scenarios are presented and assessed.