Taxpayers are funding California’s Medicaid shell game
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California’s ambulance program shows how ugly this gets. Under the state’s Ground Emergency Medical Transport program, California bars payments from the state’s general fund. Public ambulance agencies instead receive “supplemental payments” that California largely restricts to public providers, limiting private companies’ access.
The result: California pays public ambulance providers about $1,065 per transport, while it offers private ambulance companies roughly $339 for the same job.
Then the federal government matches the inflated payments.
This isn’t just favoritism. It warps the market. It pushes private providers out and leaves patients with fewer options.
California has also expanded Medi-Cal eligibility regardless of immigration status. The state claims it funds routine coverage for “undocumented” adults with state dollars, but emergency Medicaid remains federally reimbursable. Sacramento still taps federal funds through the back door, even as it sells the program as a self-funded moral gesture.
This system stinks — even when regulators bless it.
And the political contrast tells you everything. Minnesota’s fraud scandal has created enough public anger to drive its Democrat governor out of the next election. California Gov. Gavin Newsom (D), whose administration runs a program built on the same kind of federal exploitation — just with better paperwork — remains a top Democrat presidential prospect in 2028.
The federal government could stop this tomorrow. The Centers for Medicare and Medicaid Services could clamp down on the abuse of IGTs and demand a genuine state contribution, not an accounting illusion. Instead, under the Biden administration, CMS approved major expansions and encouraged the same incentives that fuel the problem.
Audits don’t fix it, either. Regulators review what states claim on paper, not what taxpayers actually fund. If a state can justify the scheme in bureaucratic language, CMS signs off. Fraud analysis often misses the point for the same reason. A state can structure IGTs so the “state share” exists largely as a bookkeeping device. Federal taxpayers remain the only party exposed to real financial loss.
Congress never designed Medicaid to serve as a revenue stream for local governments. It created Medicaid to help the poor. California’s 12-to-1 payment disparities punish the poor by reducing competition, shrinking access, and driving private providers out of business.
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Congress already has the solution. The GAO outlined it two decades ago, and the George W. Bush administration backed the basic idea: Close the loophole by prohibiting Medicaid payments that exceed actual costs for government-owned facilities.
In plain English: Stop rewarding government-owned providers with inflated reimbursements that private providers can’t touch. Set equal rules. Require real state contributions. Cut the circular funding schemes that turn Medicaid into a federal ATM.
Taxpayers don’t care whether fraud happens the Minnesota way — through day cares and nonprofits — or the California way — through health care accounting games. We care that Washington keeps subsidizing systems designed to break the rules everyone else has to follow.
California built this machine. Congress can shut it down.
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