Veteran reporters share six essential tips for investigating Medicaid stories

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 Data.Medicaid.gov, 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.