By NextBestFitStates lose control and budgets shift between levels of government
A national program takes over Medicaid from states, which changes who pays and who decides, and creates winners and losers between states.
Evidence
- State share of Medicaid was $335.0B in 2024.Sources: CMS Office of the Actuary (2025)
Who's affected
Who is hurt
- State governments: States that designed their own programs lose control, and budgets shift between levels of government.
Who gains while it lasts
None identified.
Under your mix of paths
Paths that create or worsen it
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Root causes
- Centralizing a state-run program
Open questions
- How much should states run, pay for, and decide?
Caused or worsened by these paths
This problem only matters if one of these paths is chosen.
Single public payer for everyoneTens of millions of people have no coverageChosen
A national program replaces state-run Medicaid and CHIP, along with the state choices built into them.
Cover the territories in the national program on the same terms as the statesU.S. territories get capped, lower federal health fundingChosen
National inclusion reduces territory control over program administration.
Solution paths (2)
Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.
National rules and funding, but states run enrollment and provider relations, like Canada's provinces.
- −About $1 trillion a year in administrative cost
States pay the national program what they spent on Medicaid, indexed.
- −Racial, income, and geographic disparities
- −Leaves funding vulnerable or inflexible