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A Florida doctor examines a patient. Photo: J. Pat Carter / AP

Politicians often criticize Medicaid, the public health insurance program for more than 74 million Americans, as a "broken" program that needs structural and financial changes. But the people who operate state Medicaid programs say that while the program isn't perfect, it mostly functions well.

What we're hearing: Dozens of public officials, health insurance executives, providers and consultants met in Chicago on Monday at a conference run by Health Management Associates, which has become the de facto consulting shop for the Medicaid industry and includes many former Medicaid directors and federal Medicaid staff. Many were relieved the Republican plan to cut Medicaid spending failed, but they know states have to do a better job explaining how the complex programs work today.

The Republican health care plan would have slashed Medicaid funds. There's no other way to view the congressional proposals, according to state Medicaid directors. "It would be a fundamentally different program," California Medicaid Director Mari Cantwell said. "It was about cutting the Medicaid program to be something else."

Congress could still cut Medicaid. Cantwell told me her agency is "still concerned" Congress could gut federal Medicaid funds to help pay for tax reform.

States will tinker with waivers. Seema Verma, head of the federal Centers for Medicare and Medicaid Services, has helped design many conservative Medicaid waivers. Red states may feel emboldened to copy ideas like those from Indiana. However, "innovation is not going to get you what you need," Kansas Medicaid Director Mike Randol said. What will? "Delivery system reform."

Medicaid is more than just a program for low-income people. The political fights can obscure the fact Medicaid also helps vulnerable populations including kids and adults with disabilities, frail seniors, the blind, and people who are home-bound. "We have very sick people that we're taking care of and we need to spend money on," Cantwell said. "It's not a homogenous population."

Medicaid matters a lot to the people who have it. Matt Salo, head of the National Association of Medicaid Directors, said he used to get calls every week from people who were willing to pick up and move to new states if it meant Medicaid would cover their kids' conditions. "That's the kind of motivation that really speaks to the populations we serve," Salo said.

Say hello to more managed care. Medicaid agencies continue to move away from paying for every procedure or treatment. Instead, states are paying fixed amounts of money to health insurance companies to operate the programs. But privatizing Medicaid is a polarizing issue, especially among some providers. Mario Molina, who was recently ousted from his family-owned Medicaid insurer, Molina Healthcare, acknowledged that not all managed-care programs have delivered on their promises. "There's not a lot of demonstration that managed care is actually making health better, access better, health care status better," he said.

Go deeper

Updated 7 hours ago - World

Mexican President López Obrador tests positive for coronavirus

Mexico's President Andrés Manuel López Obrador during a press conference at National Palace in Mexico City, Mexico, on Wednesday. Photo: Ismael Rosas/Eyepix Group/Barcroft Media via Getty Images

Mexican President Andrés Manuel López Obrador announced Sunday evening that he's tested positive for COVID-19.

Driving the news: López Obrador tweeted that he has mild symptoms and is receiving medical treatment. "As always, I am optimistic," he added. "We will all move forward."

7 hours ago - Politics & Policy

Sarah Huckabee Sanders to run for governor of Arkansas

Sarah Huckabee Sanders at FOX News' studios in New York City in 2019. Photo: Steven Ferdman/Getty Images

Former White House press secretary Sarah Huckabee Sanders will announce Monday that she's running for governor of Arkansas.

The big picture: Sanders was touted as a contender after it was announced she was leaving the Trump administration in June 2019. Then-President Trump tweeted he hoped she would run for governor, adding "she would be fantastic." Sanders is "seen as leader in the polls" in the Republican state, notes the Washington Post's Josh Dawsey, who first reported the news.

Coronavirus has inflamed global inequality

Illustration: Aïda Amer/Axios

History will likely remember the pandemic as the "first time since records began that inequality rose in virtually every country on earth at the same time." That's the verdict from Oxfam's inequality report covering the year 2020 — a terrible year that hit the poorest, hardest across the planet.

Why it matters: The world's poorest were already in a race against time, facing down an existential risk in the form of global climate change. The coronavirus pandemic could set global poverty reduction back as much as a full decade, according to the World Bank.