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Veteran reporters share six essential tips for investigating Medicaid stories

Veteran reporters share six essential tips for investigating Medicaid stories

Picture of Kathleen McGrory
Alexandra Olivares fills out paperwork during a visit at Inner City Health Center in Denver, a clinic that offers medical, denta
Alexandra Olivares fills out paperwork during a visit at Inner City Health Center in Denver, a clinic that offers medical, dental, and mental and behavioral health services to the underserved.
(Photo by Jason Connolly/AFP/Getty Images)

For reporters on the health beat, Medicaid is an important source of watchdog stories.

If you like following the money, there’s a lot of it there. Medicaid spending climbed to $581.9 billion in 2017, according to the Centers for Medicare & Medicaid Services.

Of course, Medicaid is more than just a follow-the-money story.

“It’s largely a children’s story, as nearly half the enrollees are kids,” says Kaiser Health News senior correspondent Phil Galewitz. “And it’s a story about giving birth, as 60 percent of births are to moms on Medicaid. And it’s a story about the elderly and disabled, as that’s where most of the spending goes.” 

But Medicaid programs and the funding mechanisms behind them can be difficult to unravel. Programs vary state to state. While the federal government has broad requirements for participation, states can apply to waive some of the rules in the name of innovation and flexibility. On top of that, most states now contract with private managed care organizations to handle the delivery of care, making the system even more opaque. 

Where’s a reporter to start? With the help of a few veteran journalists who have investigated Medicaid on the state and national levels, I put together these reporting steps for journalists at local and regional news outlets. 

1) Know your state.

It’s important to learn how your state Medicaid program works, even if you’ve covered a Medicaid program somewhere else. Liz Essley Whyte, who has done dynamite work on how drug companies influence Medicaid for the Center for Public Integrity, recommends answering a few key questions right off the bat. Is your state mostly managed care or fee-for-service? Is it one of 37 states that have expanded Medicaid as allowed under the Affordable Care Act? Does it have any federal waivers that allow it to try out new things?

“As you answer these questions you’ll start to learn the jargon you’ll need to decipher what’s being said later on,” she said. “Medicaid has its own language.”

Reports and presentations to the legislature like this one from Florida can provide a good framework for understanding the program. And reading the state budget can give you insight into how the money is being spent.

Galewitz recommends getting to know the state Medicaid director and the regulators who oversee managed care. He also notes that each state has a Medicaid advisory board. “Read minutes of their meetings or better yet, go to them,” he says.

2) Background the managed care organizations. 

List the managed care organizations in your state. Then, start to paint a picture of each organization’s finances. You can request spending and enrollment information from your state Medicaid agency. Separately, you can track down information on the organization’s revenues and expenses. For nonprofits, pull the IRS 990s. For publicly traded companies, pull the financial reports and listen to calls with investors. The Kaiser Family Foundation has excellent resources on the Medicaid managed care market, including this tracker, which provides state-level, MCO-level and parent firm-level information.

Nick Budnick, whose work at the Portland Tribune detailed a stunning lack of oversight of Medicaid coordinated care organizations in Oregon, also recommends learning how the companies exert political influence. Do they have lobbyists? Do they contribute to political committees or candidates? Are their leaders connected to lawmakers or state officials? Each avenue could lead to interesting findings. 

3) Dive into the data. 

Because Medicaid is run by the states with care delivered largely through private companies and nonprofits, national data can be hard to find. The federal government publishes some figures on eligibility, enrollment, drug utilization and drug pricing at, but the information isn’t comprehensive.

It can also be tricky to get state-level data. Andrew Chavez, whose reporting with J. David McSwane in the Dallas Morning News unearthed widespread problems with the Texas Medicaid program, says the data the state gets is usually outlined as a deliverable in the contracts with the managed care organizations. Texas, for example, has a “deliverables matrix” in its contract; deliverables include the “aggregate number of reports of abuse, neglect, and exploitation of members” and annual financial statements. Reporters can request the matrix from the state and use it to make targeted requests for data sets.

Chavez called the data sets “prime targets for data reporting.”

“There are great stories in the gap between what the state is collecting and what the state is actually looking at,” he added.

4) Get out into the field.

Real people can help you understand how the system is broken. Their stories can also humanize your coverage in a way that connects with readers and give you even more ideas for reporting. 

Some reporters have had success soliciting patients stories on social media or searching for them on sites like Yelp, GoFundMe and Facebook. You can also contact patient advocacy groups, but you should do some reporting to do first, Budnick said. “Figure out who is funding the patient groups to get an idea of possible agendas,” he cautioned.

Doctors, nurses, mental health practitioners and facility administrators also know the gaps in the system and can point you in the right direction.

5) Read the audits, complaints and Inspector General’s reports.

The U.S. Department of Health and Human Services’ Office of Inspector General posts its reports and enforcement actions online. You can search by keyword. Last month, the office used a sample of capitation payments to estimate that California paid managed care organizations more than $70 million on behalf of dead people from July 2014 through December 2017.

State agencies also audit and investigate their Medicaid programs. A growing number are posting the reports online. In addition, you can request the complaints that have been filed against managed care organizations. If the complaints are too heavily redacted, request the number of complaints that have been filed against each organization.

6) Hit the courthouse.

Pull the lawsuits against the provider or managed care company you are investigating. Pay close attention to False Claims Act lawsuits, Essley Whyte says. The documents often detail the company's business practices — and how it allegedly tried to bilk Medicaid. 


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You may want to review the state by state funding of primary care by insurance payer type

The places with concentrations of the worst public and private plans are where shortages of workforce exist.
Payments tend to be the worst where health care workforce is least.

Medicare, Medicaid, Dual Eligible, Veteran, High Deductible plans are concentrated in 2621 counties shortest in health care workforce.

Before and after Medicaid expansion - these shortages existed.

Expansions did not address payments below cost of delivery, especially from Medicaid.

These counties have 40% of the US population including 75% of the rural population and 32% of the urban population. Together with populations that have the worst plans - and barriers to health access - over half of the nation has half enough generalists and general specialists

2621 counties lowest in concentrations

97.9% Counties with No Hospital in County
97.4% Low Education County 2004
84.1% One Hospital Counties
75.0% Rural population of US
50.0% Veterans estimate
49.8% Number Diabetics 2013
46.9% Disabled Work Benefit Pay $ Dec2010
45.1% Total premature deaths
43.4% SocSecBenefitPayment $ Dec2010
43.4% NumbChildreninPoverty2013
42.2% SNAP Pay $ 2010
41.6% Persons in Poverty 2009
41.0% Numb Unemployed 2013
40.7% Number Uninsured 2014 - not much difference, these counties were not higher in uninsured, they just have the worse insurance plans, least supportive of local workforce
40.2% pop2010
36.3% Active FM docs 2013 - Only MD DO NP and PA filling family practice positions are found with population based distribution or 36% for this 40% of the US - when not in family practice or when leaving - the workforce concentrates where there is already concentrations
32.0% Urban population of US
27.4% Bach Graduate Prof Degree 2000 - behind in education advancement
27.2% General Surgery 2013 Active (AMA Masterfile) - falling fast and oldest in these counties
26.9% Physician Assistants with NPI 2010
25.8% Advanced Practice RN w NPI 2010
25.5% Office Code $ for 99214 - These practices are paid 15% less in these counties and the dollars distributed match up to the workforce involved in office based care. You cannot increase the workforce without increasing the dollars. If you cut the payments or require substantially higher costs for metrics measurements and micromanagements - you are killing workforce, jobs, economics, and more where they are most needed. Value based designs discriminate via penalties for not having EHR and because these practices care for populations with lesser outcomes and lesser local resources (and other factors)

24.0% General Orthopedics
23.5% Mental Health Providers 2013 (note psychiatry at 14.8% below) - These are counties with arguably 45% of mental health problems, with concentrations of substance abuse, with elderly and oldest of the elderly, with disabled and veteran concentrations but only about 15 - 28% of various mental health workforce. Psychiatry and geriatrics are concentrated in concentrations - far away from these counties. Cancer evaluation and treatment is similarly out of position.

22.5% NonFP PA

22.2% Obstetrics-Gynecology - Women's health funding has also been difficult with low payments and higher costs of delivering care. Losses of hospitals and losses of labor and delivery hurt also.

22.1% Emergency Medicine - Emergency and hospitalist workforce are about the only specialties increasing in these counties - but they are increasing much faster in counties higher in concentrations of workforce. Also the costs of emergency and hospitalist physicians are a huge strain on these financially challenged hospitals. No study demonstrates benefits for the smaller and medium size hospitals (such as a half day of hospital stay saved). The research has all been about academic and larger systems. But these changes have worsened the budget situation for hospitals where needed.
20.2% Pediatrics - pediatrics is stable, but distributes poorly
19.8% General Internal Medicine - is collapsing - essentially the NP and PA gains are filling the gaps (but are not increasing primary care delivery capacity)
19.0% Physician Born in County The AMA Masterfile has birth origins and those born in these counties are half as likely to become US trained physicians - and are even more dilute due to other sources outside the US. The African American admissions are similar at half the US level. In the counties most behind in education and income, the ratios are half of this level - similar to Mexican American.
14.8% Psychiatry
14.6% Hematology Oncology
14.4% Internal Medicine Geriatrics
13.0% Estimate of US Health Spending - based on AMA data regarding the impact of various specialties, this is the proportion attributable to physician contributions. Notice that the expanded insurance plans take many more billions from these counties and do not return dollars to these counties to support local workforce, local health access, local jobs, or local economics

6.6% Residents in Training in 2013 - This 40% of the population only has 6.6% of residents trained locally. Family practice may have about 12% as it is better distributed - but still far from 40%. Recent GME changes are small and are unlikely to change this.

The population is growing fastest in these counties - about twice as fast as the US population growth. Note that counties highest in concentrations are growing in workforce, but not in population. In contrast the workforce is stagnant to declining in these counties growing fastest in numbers, demand, and complexity. This is a contrast with rural populations that are stagnant. A rural focus is distracting as only a small portion is involved and 25% of the rural population is doing reasonably well for only about 30 - 40 million behind. The 2621 lowest concentration counties are growing fastest and involve over 130 million people.
40.2% pop2010
39.2% pop2000
38.6% pop1990
38.4% pop1980
36.6% pop1970

21.1% NonFP NP
20.8% Active 2013 Physicians
20.6% Otorhinolaryngology
20.4% Urology
18.4% Non FM Docs

The family practice multiplier for distribution is about 3.3 times greater to these counties, the same as for rural locations. But family practice result for MD DO NP and PA is shrinking as the financial design is much better away from primary care, especially away from family practice.

And Practice Numbers That Matter Most

Primary care finances in these counties are down about 8 billion dollars since HITECH, MACRA, and PCMH (adjusted for low penetration) without all of the worsening costs of delivery considered.

Where 38 billion once supported primary care a decade ago (the primary care practices in 2621 counties had a 25% share of the nation's annual primary care revenue of 200 billion adjusted for lower payment and lower collections).

After calculations per primary care physician per year for HITECH to MACRA to PCMH adjusting for lower penetration - there is only 30 billion a year to support primary care delivery. It is not a surprise that fewer doctors have certified EHR due to the costs and others are considering leaving or retirement as these physicians are older.

There is no research documenting the problems created but likely are fewer team members and more compromised practices.

The actual revenue could be lower if closed practices were considered along with declining primary care volume and lesser productivity.

It is not just a rural situation. It is and has been a crisis situation for over 100 million people for some time - and for those who attempt to care for them. And this could grow to 170 million by 2040 as the population increases faster, as more compromises continue, as housing forces more out of higher workforce concentration counties, and as more burnout, turnover, or retire.

Bob Bowman
Basic Health Access


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