The Bush Administration’s Health Insurance Flexibility and Accountability (HIFA) initiative offers expedited review of waivers that includes a premium assistance component. It also significantly weakens the benefit and cost-sharing protections for families participating in premium assistance programs and relaxes the cost-effectiveness test. This issue brief examines the new federal polices associated with using Medicaid and/or SCHIP funds to promote private insurance options, the ways that states have responded to these options, and the key questions to consider regarding premium assistance programs.