57% of Medicaid Now Flows Through Plans States Can't Fully Audit
Summary
MACPAC's June 2026 Report to Congress finds managed care capitation grew from 23.5% to 57.3% of all Medicaid benefit spending between FY2010 and FY2023 -- almost $500 billion a year, with 74.1% of beneficiaries now in full-risk plans. Yet states' reporting of sanctions, corrective action plans, and liquidated damages against noncompliant plans is, in MACPAC's words, inconsistent and incomplete. No public database lets , states, or beneficiaries see which plans are actually held to account.
MACPAC's June 2026 chapter⧉ traces the shift: 74.1% of beneficiaries⧉ sat in full-risk plans in FY2023, up from 48.3% in FY2010. The federally mandated Managed Care Program Annual Report is supposed to log every sanction, corrective action plan, and liquidated damage against a noncompliant plan. It doesn't.
View data as table
| FY2010 | 23.5% | Under a quarter of Medicaid benefit spending |
|---|---|---|
| FY2023 | 57.3% | Over half -- almost $500 billion in capitation payments |
Across the 34 states⧉ that reported for 2023, MACPAC counted 737 accountability actions -- 359 corrective action plans, 187 liquidated damages, 106 civil penalties. But the counts don't reconcile. One state's report⧉ logged a single $2,500 sanction while its own website showed $33.8 million in liquidated damages the federal filing never captured. A separate study found about 25% of reported sanctions⧉ listed no remediation at all.
View data as table
| Corrective action plans | 359 | 25 states; only 12 carried a financial penalty |
|---|---|---|
| Liquidated damages | 187 | 10 states; average sanction $37,962 |
| Civil monetary penalties | 106 | 11 states; average sanction $402,833 |
| Compliance letters | 66 | 8 states; no financial penalty attached |
| CAP + liquidated damages | 19 | Just 2 states reported this combined action |
There is no publicly available database⧉ linking the data so , states, or beneficiaries can see which plans are actually held to account. MACPAC's fix is two recommendations: define what belongs in the report, and build the database that doesn't exist.
- The money moved; the oversight didn't follow. Capitation went from 23.5% to 57.3% of Medicaid benefit spending in 13 years -- roughly 2.4x -- yet the federal report meant to track plan accountability is inconsistent and incomplete by MACPAC's own account.
- The sanction ledger doesn't reconcile. One state's MCPAR captured a $2,500 sanction while its own dashboard showed $33.8 million in liquidated damages -- an understatement of more than 13,000-fold -- and about a quarter of reported sanctions list no remediation.
- No one can see the whole picture. With 74.1% of beneficiaries in full-risk plans, there is still no public database linking the reported data -- so , states, and enrollees can't tell which plans are being held to account.
Figures are MACPAC's June 2026 Report to Congress, Chapter 3. Spending and enrollment shares span FY2010-FY2023; the sanction counts (Table 3-2) come from MACPAC's analysis of Managed Care Program Annual Reports for performance year 2023, covering 34 states. The state with the $33.8M discrepancy is unnamed here per MACPAC's own presentation.
Sources(2) ▾
- Medicaid and CHIP Payment and Access Commission (MACPAC), State and Federal Tools for Ensuring Accountability of Medicaid Managed Care Plans (Report to Congress on Medicaid and CHIP, Ch. 3) (2026-06-01) — Chapter 3 of MACPAC's June 2026 Report to Congress. Traces managed care's rise (capitation from 23.5% to 57.3% of Medicaid benefit spending, FY2010-FY2023; enrollment 48.3% to 74.1%), analyzes the sanctions and corrective-action data states submit on the Managed Care Program Annual Report (MCPAR) for 34 states in performance year 2023 (Table 3-2), and documents that reporting is inconsistent and incomplete. Source of every load-bearing figure here. macpac.gov · original document
- Medicaid and CHIP Payment and Access Commission (MACPAC), State and Federal Tools for Ensuring Accountability of Medicaid Managed Care Plans (publication landing page) (2026-06-01) — MACPAC's official landing page for the chapter, hosting the PDF and the two Commission recommendations (3.1: clarify MCPAR sanction reporting; 3.2: build a publicly available managed care performance database). Confirms authorship and publication date. macpac.gov · original document
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Medicaid now routes 57.3% of its benefit spending⧉ -- almost $500 billion a year -- through managed care plans in FY2023, up from 23.5% in FY2010. It is the report states can't fully audit: MACPAC's own review found plans' sanction records "inconsistent and incomplete."⧉