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Now is the Time to Modernize Communication in the Medicaid Program

By ABNER MASON

What do television shows 60 Minutes, Roseanne, Designing Women, and Murder, She Wrote all have in common? They were top 10 prime time shows in the 1991 – 92 season according to Nielson Media research. Obviously, what Americans want to watch has changed in 34 years. The decline in market share the major networks – ABC, CBS, and NBC – have experienced, and the dramatic growth of streaming services proves the point. It makes sense to let people watch what they want to watch on the device of their choice, and use new technologies like streaming services to access the shows they want to watch.  It would be foolish for us to insist that Americans watch only shows from the legacy networks on traditional TVs. But this is basically what we are doing now when we force Medicaid Managed Care Plans (Plans) to comply with a 1991 Federal Law when they communicate with Medicaid recipients.

Here’s the problem. Federal legislation called the Telephone Consumer Protection Act (TCPA), enacted in 1991, makes it very difficult for States and Plans to use text messaging to communicate with their members, even though texting is the primary, and preferred mode of communication for all Americans including Medicaid recipients. TCPA requires a State or Plan sending a text to have permission from the person receiving the text before the text is sent. Violations of TCPA result in significant financial penalties for each infraction, and penalties are tripled if the sender knowingly sent the text without consent.

Medicaid recipients are typically assigned to Plans, they do not choose their Plan, and as a result, in light of TCPA, and potentially enormous financial penalties being assessed, plans have taken the position that they do not have consent from recipients to text them. And that is the problem.

Texting is the way most Americans communicate today. Other modalities like US mail (called snail mail for a reason), phone calls (who answers calls anymore?), and email (likely to go without a response for days or weeks) are dramatically less effective. Because they are low income, many Medicaid recipients often do not have a landline, or a laptop. They rely on their mobile phone for all their communication, including healthcare related communication. Texting is their preferred, and often only way of communicating.

As Founder and CEO for SameSky Health, I spent over a decade working with Plans to help them engage their members and navigate them into healthcare at the right time and the right place. Again and again, we found when we could maneuver around the outdated restrictions TCPA placed on Plans, we got higher engagement which translated into more well child visits, more breast cancer screenings, more diabetes (a1c) screenings, and so on. Using modern tools of communication is a way of meeting people where they are. It builds trust and leads to better health outcomes. But sadly, because of TCPA, we were not able to text members in most instances.

What has been a significant problem will be made exponentially worse when Federal Work Requirements are implemented as now seems likely. A Federal Medicaid Work requirement will dramatically increase the need to modernize how States and Plans communicate with Medicaid recipients. Compliance with TCPA is standing in the way of this modernization. And if it is not fixed, many, many people will lose their Medicaid benefits for purely procedural reasons.

To improve health outcomes, allow efficient communication to verify work status,  and provide twice yearly redetermination information, States and Plans must be exempted from the outdated provisions of TCPA. Senate action on, and final passage of the Reconciliation legislation offers the best opportunity to get an exemption from TCPA passed and signed into law.

The time to act is now.

So lets focus on (1) getting the exemption language in the Senate version of the Reconciliation legislation, (2) working with HHS and CMS to ensure post legislation guidance directs States and Plans to include texting as a best practice when implementing work requirement programs and communicating with recipients more generally, and (3) implementing a media strategy to build support for using modern technology to create easier more efficient ways for Medicaid recipients to comply with the new work requirements.

We have two months – June and July – to get action on an exemption in the Senate, and the remainder of the year to influence Administration guidance on work requirement programs.

Medicaid beneficiaries will be the biggest winners if we succeed because an exemption is a key strategy to reduce unnecessary loss of Medicaid benefits.

What can you do? Call your Senator and ask them to support modernizing how States and Plans communicate with Medicaid recipients. And please share this blog post with your network.

Abner Mason is Chief Strategy and Transformation Officer for GroundGame Health. He serves on the Board for Manifest MedEx, California’s largest health information exchange, is Vice-Chair of the Board for the California Black Health Network, and is a member of the National Commission on Climate and Workforce Health. Here are are just some of articles and interviews he has published over the past 10 years pushing for States and Plans to be able to text Medicaid recipients. 

Medicaid Budget Cuts: Hospitals will bear the burden, we will pay the price

By LINDA RIDDELL & THOMAS WILSON

Recent discussions over Medicaid budget cuts invite us to look more deeply into the house-of-cards that, when it collapses, will hit the states and low-income households hardest. But we will all be harmed.

Some states get 80% of their Medicaid funding from the federal government, as a recent Wall Street Journal article, “Medicaid Insures Millions of Americans. How the Health Program Works, in Charts” pointed out. Even states relying less on federal funds will be hard pressed to shift their resources to replace the federal share. The ripple effects are clear: states are likely to reduce Medicaid enrollment, forcing low-income people to skip care or find free care, and hospitals will shift resources to cover care they are not paid for. Dollars cut from Medicaid do not vanish; they simply shift to different corners of the healthcare system. Ouch!

A Deep Dive into the Facts

Fact 1. Low-Income Households Already Spend More of Their Income on Health Care: Recent Consumer Expenditure Survey data reveals that the lowest 20% of households—roughly corresponding to those enrolled in Medicaid—saw the share of their income spent on healthcare (red in Figure below) rise from 8% in 2005 to 11% in 2023. In contrast, the highest-income 20% devoted only 2% in 2005, rising to about 4% of their income to healthcare in 2023.

Fact 2. Necessities Consume a Majority of Low-Income Households’ Income: Low-income households spend about 57% of their income on essentials like food and housing (blue in figure). This leaves little to nothing for other expenses. These families have an almost inelastic budget where any additional expense, even one as critical as medical care, forces painful trade-offs. In contrast, high-income households have from 38% to 53% of their income (purple in figure) left over after meeting all basic and other costs.

Fact 3. Affordable Care Act Led to Reduced Uninsured ED Visits: In 2016 — two years after Affordable Care Act provisions took effect —  many states expanded Medicaid, and all introduced health insurance exchanges. These changes brought emergency department visits by uninsured patients down by half—from 16% to 8%.

Fact 4. Uncompromising Obligations at Hospitals: Under the U.S. Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must treat and stabilize every patient who arrives, regardless of their ability to pay. With around 70% of all hospital admissions arriving via the ED, a surge in uncompensated care in the ED will directly affect admission rate, the hospital’s core function.

Examining the Key Inferences

Inference 1. Rising Uninsured Populations: Cutting Medicaid budgets is likely to lead to states shrinking enrollment and boosting the number of uninsured individuals.

Inference 2. A Resurgence in Uninsured ED Visits: If Medicaid budget cuts reduce enrollment, the previously achieved reductions in uninsured ED visits could return to the high rates seen before the ACA.

Inference 3. Hospitals Caught in the Crossfire: Budget cuts will force hospitals to provide more uncompensated ED care. The response is likely to be reducing staff, the hospital’s largest cost center  — a move that directly affects the quality and timeliness of both primary and specialty services. Washington state offers a cautionary tale, where hospital leaders predict longer wait times and lower service levels due to state budget cuts.

Broad Impacts Beyond the Numbers

The health system must pick up the $880 billion slack, not by magically creating money but by shifting resources from other programs.  The healthcare system has its priorities set by the budget scramble–not by the community’s health needs. Health disparities between the rich and poor will widen, and progress made on having more people insured will reverse.

Staff cuts will lengthen wait times and decrease service quality, not to mention they will burn more people out of their health service jobs. The ripple effects of Medicaid cuts will eventually touch all who seek medical care and pay for health insurance.

A Call for Political and Community Action

Now, more than ever, it is time for political stakeholders to recognize that the real cost of Medicaid cuts is borne not just by states but also by communities. Stakeholders, policymakers, community leaders, and the general public must stand up for their own interest in having a sustainable health care funding approach.

Toward a More Equitable Future

The case against Medicaid budget cuts is not merely about dollars and cents—it is about the future of our healthcare system and the health of millions of Americans. Cutting Medicaid benefits may create short-term savings on paper, but it undermines the health infrastructure that serves everyone.

A thoughtful and balanced approach would protect vulnerable populations while ensuring hospitals remain viable centers of care, especially for rural areas. In rural communities, the health sector creates 14% of jobs; rural hospitals are generally the largest employer and since they serve more Medicaid and Medicare patients, they will be the hardest hit by these budget cuts.

The shift in where healthcare dollars are spent could change every layer of healthcare delivery—from the ED’s ever-growing responsibility to inpatient admissions to primary care’s dwindling resources. It is a call for all of us to rethink how healthcare is funded and to stand in solidarity with those at risk of being left without medical care.

Looking Ahead

Beyond the immediate fiscal challenges, this issue invites a broader discussion on healthcare reform. How can we restructure funding to improve efficiencies? Could community health cooperatives or expanded telehealth services help lessen adverse effects?  These questions deserve robust debate and decisive action.

In these turbulent times, every stakeholder—from local communities to federal policymakers— needs to find solutions that prioritize human health over short-term budget tactics. The stakes are high, and the choices made today will shape healthcare access and quality for decades to come.

Linda Riddell, MS is a population health scientist specializing in poverty and is the founder of Gettin’ By, a training tool helping teachers, doctors, case managers, and others work more effectively with students, patients and clients who are experiencing poverty. Thomas Wilson, PhD, DrPH is an epidemiologist focused on real-world issues and board chair of the non-profit Population Health Impact Institute 

Medicaid Should be Abolished. But Not Like This!

By MATTHEW HOLT

A long time ago in a different country, there was a landslide election from a population looking for change. And change they got. Americans had been campaigning for national health care since 1917. There had been failures in 1933 and 1946 and 1961. But in 1965 they got it. Sort of.

But a weird thing happened in the Congress. Out of the political sausage making came a plan that “Cared” for those over 65. While another plan came out that “Aid”ed the poor. (Stole that from the wonderful Adimika Arthur). Weirder still, the Medicare program was and is a Federally-funded program. The Medicaid program was a state-administered program, even though it was at least half funded by the Feds. 

That meant that Medicaid was always vulnerable to the whims of states. Of course many states already had demonstrated dismal records in how they treated their poorer and minority populations in the past (think slavery, Jim Crow, KKK, separate schools, drinking fountains, buses…you get the idea).

So while Medicare became the savior program for anyone who made it to 65, and later for those who were disabled or had kidney disease, Medicaid was a program for poor people that then got treated poorly. (Stole that from Jonathan Cohn). And right now in 2025 it is under severe threat yet again.

Before we get to that threat, it’s worth looking at the program. Medicaid has evolved and now covers most nursing home care (for “poor” seniors), care for the disabled, and even pays Medicare Part B premiums for people too poor to pay their own.  It also covers health insurance for poor people under 65 and in those states that accepted ACA Medicaid expansion, that’s a considerable number. Of course these are people under an imaginary line that makes them too poor to buy on the exchanges set up by the ACA. And usually Medicaid includes the CHIP program, an insurance program that covers poor children set up under Clinton in 1997.

This chart from the venerable KFF shows that while 75% of people on Medicaid are, poor, under 65, and not classified as disabled, 50% of the money goes to those who are not.

This all results in a bizarro world in which there is one Federal government program for people over 65 and the disabled, and then an entirely different state-based one, which spends 1/2 of its money on people who are over 65 and disabled and who are also in the Federal program. This is plain stupid and always has been.

Of course there is more to it than that.

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Streamlining Public Benefits Access is a Must to Address Poverty

By ALISTER MARTIN and TARA MENON

If a friend were to ask you which state, Massachusetts or Texas, has a more streamlined federal benefits enrollment program, what would your guess be?

Having screened over 17,000 families and helped them obtain more than $1.8M in federal and state aid through our work in both Massachusetts and Texas, our experiences doing federal benefit enrollment have led us to a surprising conclusion: Texas is leading the way. While Massachusetts has room for improvement, this issue extends beyond a single state—many other states face similar challenges with complex and fragmented benefits systems.

At Link Health, where our work spans the bustling neighborhoods of Boston and Houston, this revelation has been both a surprise and a call to action. In many underserved communities, through partnerships with Federally Qualified Health Centers, our organization seeks to assist eligible people in the navigation and enrollment in benefit programs that address crucial needs like access to affordable internet, food access, healthcare support, and housing resources.

One of the main obstacles we’ve encountered is that people are often unaware of the benefits they qualify for or find the process overwhelming. In states like Massachusetts, separate applications are required for each benefit program, making it harder for families to get the help they need. Programs such as LIHEAP, which offers heating subsidies, Lifeline, which provides internet access for telehealth, and SNAP, which helps with food assistance, all come with different paperwork and requirements. This fragmentation creates unnecessary barriers.

This is not unique to Massachusetts. Across the U.S., many states have similarly disjointed systems, leaving millions of dollars in federal aid unclaimed. It’s estimated that around $140 billion in federal aid goes unclaimed each year due to these inefficiencies.

In contrast, we have found that Texas’s “Your Texas Benefits” platform is efficient and user-friendly. This centralized, comprehensive application process covers a wide range of state benefit programs, including SNAP, TANF, Medicaid, and CHIP, as well as other services like WIC, family violence support, adult education, and substance abuse prevention programs. This unified system allows users to apply for multiple programs through a single portal, streamlining the process considerably. Plus, this common application system allows groups like ours to efficiently connect patients with the help they need without the usual bureaucratic entanglements — it benefits us both.

Although Massachusetts made some progress with its limited common application for MassHealth and SNAP in 2021, it still doesn’t offer a fully unified system for all its programs. This means that many residents must continue navigating multiple applications and processes. During the recent Medicaid “unwinding,” people across the U.S. lost coverage because they couldn’t manage the renewal process. It’s estimated that between 8 million and 24 million people are at risk of losing Medicaid benefits nationwide(Center For Children and Families), not because they no longer qualify, but because of these application challenges.

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Supporting innovations in cancer treatment and prevention for our nation’s most vulnerable

By KAT MCDAVITT and LESLIE KIRK

Innsena has made a $100,000 contribution to CancerX, making Innsena the public-private partnership’s first Impact Supporter.

Why? There are few conditions in which the disparity in innovations benefiting underserved communities is more apparent than in the treatment and prevention of cancer.

Patients without insurance are more likely to present with more advanced cancers, and the cancer death rate for people of color is significantly higher than for white patients. More people die from cancer in rural communities than in urban settings. 

In CancerX, we found a community of partners taking on hard problems to equitably deploy innovative solutions that can reduce the risk of, and cure cancer for all patients. Even—and especially—when financial incentives do not otherwise exist for the private sector to solve those problems.  

Innsena is committed to improving equitable access, treatment and outcomes for the most vulnerable among us. We focus on supporting improved outcomes for Medicaid members and underserved communities. The disparity caused by the absence of incentives and funding for innovators to enter the Medicaid market can’t be overstated. 

But innovators, and the investors who fund these pioneers, are exactly what our industry needs to change health outcomes in underserved communities. 

We decided that, if the incentives to innovate in cancer care for vulnerable populations don’t exist, then we would create them. Our financial commitment to CancerX is a step forward that we hope will start a broader movement. 

Our team’s $100,000 contribution will help the team at CancerX to accelerate programs underway—including its effort to improve equity and reduce financial toxicity in cancer care and research—and to more rapidly launch new initiatives. 

We’re particularly proud to support the public-private partnership’s efforts to improve equity and reduce financial toxicity. Cancer deaths are inequitably distributed across the United States—and those patients who do survive are 2.5 times more likely to declare bankruptcy than those without disease. 

Likewise, a key component of CancerX is a start-up accelerator for companies bringing more digital solutions for the treatment and prevention of cancer, with special attention given to organizations that focus on disadvantaged populations. We’re honored to support the start-ups selected for the first CancerX accelerator cohort with both mentorship and financial support. 

And to that end, as individuals, we’ve gone one step further to support start-ups focused on preventing and curing cancer for vulnerable patients. We’ve also partnered with Ben Freeberg and his team at Oncology Ventures to ensure that digital health start-ups innovating for all patients in the oncology space have funding available to advance their causes. 

Innsena is joining more than 150 organizations already working together to make a difference for all patients in the prevention and treatment of cancer. CancerX is co-hosted by the Moffitt Cancer Center and Digital Medicine Society, alongside the US Department of Health and Human Services Office for the National Coordinator for Health Information Technology and Office of the Assistant Secretary for Health. 

We need more innovators working to improve care for the underserved. Join us in supporting CancerX. As a community we’ll make a difference. 

Kat McDavitt is President and founding partner of Innsena. Leslie Kirk is CEO and managing partner of Innsena.

Who Could (Possibly) Be the Ideal “Chief Patient Officer”?  (And Other Ideas that Sound Better on Paper than in Practice)

By JONATHON S. FEIT

If ideas presented in essays on The Health Care Blog and other healthcare forums are meant to be rhetorical, without intention of turning notions into reality on behalf of patients who need genuine, intimate, desperate help…then feel free to ignore this essay entirely. 

Some among us—the State of Washington’s Co-Responder Outreach Alliance; Lisa Fitzpatrick’s Grapevine Health, which specializes in “street medicine” and advocacy in and around Washington, D.C.; Thorne Ambulance Service, an inspirational ambulance entrepreneur bringing both emergency and nonemergency medical transportation to underserved rural spaces (and more) across South Carolina; and the RightCare Foundation in Phoenix, a firefighter-driven organization dedicated to ensuring that patients’ needs and wishes are honored during critical moments, spring fast to mind—are stretching hands across the care continuum while pounding the table for interoperability at scale because PEOPLE. ARE. FALLING. THROUGH. THE. CRACKS. AND. DYING.  

Thatincludes responders who run toward the crises; into alleys; who risk their own lives, health, psyches, families, and futures because, as Josh Nultemeier—Chief Paramedic and Operations Manager of San Francisco’s King-American Ambulance, and a volunteer firefighter in the Town of Forestville—put it so simply in a social media post: “People could get hurt.” Moral override—that matter-of-fact willingness to risk himself for strangers who lack any other path to save themselves—is what makes Josh (and others who believe as he does) heroic.

Solving problems like substance use disorder—coupled with an increasing awareness of the lack of interoperability with prescription drug monitoring programs (PDMPs), many of which are run by Bamboo Health, which today imports zero data regarding out-of-hospital overdoses—is urgent. If an overdose is reversed in an alley, an abandoned home, a tent or “under the bridge downtown,” by an ambulance, fire, or police service pumping Narcan to get breathing going again, the agency’s lifesaving efforts get zero “credit” in the data. The downstream effects of this information sharing breakdown make it difficult to settle for less-than-bona fide interoperability: there is neither time to waste nor margin of error, yet hospitals and healthcare systems cannot even “see” the tip-of-the-tip-of-the-spear.

A similar emotionality makes it difficult to tolerate lamentations about information sharing when states like California—and the federal Office of EMS, inside the National Highway Traffic Safety Administration—are transforming interoperability into a standard operating procedure. As a listener to the “Health Tech Talk Show” since its start, I have struggled with hearing Lisa Bari and Kat McDavitt deride whether interoperability is “real.” It is real. It is happening, and has been automated for years—for example, with both the Quality Health Network and Contexture (formerly CORHIO) in Colorado—empowering agencies of all sizes to care for patients experiencing healthcare emergencies, and those who have children with Duchenne’s Muscular Dystrophy and other diseases. Such efforts should be celebrated for their meaningful impact on patients who rely on ambulance services to get them the care that they need—and sometimes to get them to the care that they need. 

Yet no panel at the national conference for CIVITAS was dedicated to interoperability to or from ambulances, despite that some of America’s most active health information exchanges—coast to coast—have automated interoperability involving Fire, EMS, Non-Emergency / Interfacility Medical Transport, Critical Care, and Community Paramedicine. No mention highlighted widespread efforts to make POLST forms accessible to Mobile Medical professionals, thanks to prioritization of the ethical treatment of medically frail patients after COVID-19 and a New York Times piece called “Filing Suit for Wrongful Life.”

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Poor Kids. Pitiful Us

By KIM BELLARD

Well, congratulations, America.  The child poverty rate more than doubled from 2021 to 2022, jumping from 5.2% to 12.4%, according to new figures from the Census Bureau.  Once again, we prove we sure have a funny way of showing that we love our kids.

The poverty rate is actually the Supplemental Poverty Measure (SPM), which takes into account government programs aimed at low income families but which are not counted in the official poverty rate. The official poverty rate stayed the same, at 11.5% while the overall SPM increased 4.6% (to 12.4%), the first time the SPM has increased since 2010.  It’s bad enough that over 10% of our population lives in poverty, but that so many children live in poverty, and that their rate doubled from 2021 to 2022 — well, how does one think about that?

The increase was expected. In fact, the outlier number was the “low” 2021 rate.  Poverty dropped due to COVID relief programs; in particular, the child tax credit (CTC).  It had the remarkable (and intended) impact of lowering child poverty, but was allowed to expire at the end of 2021, which accounts for the large increase. We’re basically back to where we were pre-pandemic.

President Biden was quick to call out Congressional Republicans (although he might have chided Senator Joe Manchin just as well):

Today’s Census report shows the dire consequences of congressional Republicans’ refusal to extend the enhanced Child Tax Credit, even as they advance costly corporate tax cuts…The rise reported today in child poverty is no accident—it is the result of a deliberate policy choice congressional Republicans made to block help for families with children while advancing massive tax cuts for the wealthiest and largest corporations.

Many experts agree: child poverty, and poverty more generally, is a choice, a policy choice.

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Matthew’s health care tidbits: Time to get Cynical

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Plenty of reason to worry about the future of American health care this week. The biggest for-profit hospital chain–HCA–was accused of aggressively pushing patients into hospice care, sometimes in the same room, in order to make their hospitality mortality numbers look better. Most of the leading benefits consulting companies were exposed as taking payments from PBMs–yup, the same organizations their employer clients thought they were negotiating with on their behalf. And one of the biggest names in digital health, Babylon Health, tumbled into destitution, taking billions of dollars with it and leaving uncertain the fate of the medical groups in California it bought less than two years ago. Even the most successful capitalists in health care — United HealthGroup and its fellow insurers — saw their stock fall because apparently outpatient surgery volume is ticking up. 

On the policy front the malaise is spreading too. The end of the public health emergency (remember Covid?) is being used as an excuse by the old  confederate states to kick people off Medicaid. Georgia and Arkansas appear to be bringing back work requirements, even though I thought CMS has banned them and every study has acknowledged that they are cruel and ineffective. About 20 million people got on to Medicaid during the public health emergency and KFF estimates up to 17 million may be kicked off, while over 1.7 million already have.

Finally an article by Bob Kocher and Bob Wachter in Health Affairs Scholar remins us that big academic medical centers are nowhere near ready for value-based care (VBC). Jeff Goldsmith has been vocal on THCBGang and elsewhere about how VBC is becoming a religion more than a reality. And I remind you that Humana’s MA program is still basically a Fee-For-service program in drag (even though that’s now illegal in their home state). 

I grew up in American health care expecting that eventually a combination of universal insurance mixed with value-based purchasing would lead to a series of tech-enabled companies doing the right thing by patients and making money to boot. With the managed care revolution, the ACA and the boom in digital health all firmly in the rear view mirror, the summer of 2023 is a lesson that you can never be too cynical about health care in America.

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All Three Legs of the Obamacare Stool Are Working Well – Part 2

BY GEORGE HALVORSON

2022 Medicare Advantage data gathering process change made last year just made upcoding for plans irrelevant and impossible, but the critics do not accept that it happened. 

CMS just ended that upcoding debate for 2022 by completely killing the coding system for the plans, effective immediately. The plans can’t code risk levels up because the coding system was eliminated entirely for 2022.

RAPS is dead.

The payment approach for Medicare Advantage now has no upcoding components and the government just used their new and more accurate numbers to create the 2023 payment level for the plans.

The numbers went up a bit with the real risk levels because the plans actually seemed to have been undercoding in spite of their best efforts to have higher numbers in their RAPS data flow.

We should now be able to put that issue to bed and look at what has been accomplished overall by the Affordable Care Act.

The Medicare Payment component of the Affordable Care Act just evolved to a new level — and the entire Obamacare package should now be recognized for what it is now and what it has become. 

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All Three Legs of the Obamacare Stool Are Working Well

• 3

BY GEORGE HALVORSON

When the Affordable Care Act was passed, the politics were so intense and the debates were so filled with rhetoric in all directions that most people actually didn’t understand that there were three major component parts to the strategy and program that function very directly as a package, and should be looked at now in the context of several years of implementation to see how each part of that law is currently doing.

Medicaid was our first priority.

The first component part — and the one that had the highest need for passage when the law was passed because we were doing such a horrible job as a country in providing coverage to our children and to our low-income people — was Medicaid expansion.

We were the only country in the industrialized world that did not have health care available to our low-income children, and that deficiency damaged so many people and was so terrible as a reality that we needed to correct it as soon as we could.

That program is on the right track.

Most states have now used the full Medicaid package and we now have a total of 90 million people enrolled in Medicaid. About 41 million of the members are in the CHIPS program, and a majority of the births in a majority of the states are now Medicaid births.

The states have all used a number of modern care improvement tools to provide and deliver significantly better care than the old Medicaid programs that are far too often delivered to their beneficiaries.

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