Edge of the Story
True stories of overlooked witnesses at pivotal moments in history and the events they quietly observed.
Edge of the Story
S2 E5 - When The Guardrails Come Off
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On June 2, 2026, the Administrator of Medicare and Medicaid stood at a White House podium. He was answering a question about fraudulent Affordable Care Act enrollments — five to six million people, some of whom did not know they had been enrolled. Then he said something else in the same answer that nobody in the room paused on.
"We completely took the guardrails off. And I know this because I'm working in the agency that actually was told to take the guardrails off."
He used the word told. Someone gave the instruction. Tonight on Edge of the Story, we investigate who.
This is the systems episode. The architects behind the architecture. Deloitte operates Medicaid eligibility systems in approximately 25 states — half the country. Documented audits in Tennessee, Texas, Florida, and Kentucky show systems that erroneously terminated coverage for eligible patients, erroneously approved coverage for ineligible ones, and produced billions in improper payments. When the systems failed, the state agencies did not switch vendors. They hired Deloitte to fix the systems Deloitte had built.
The cleanest example is Electronic Visit Verification. Federal law required it in 2016. States spent $146 million in Ohio alone to build the systems. New York State paid $14.5 billion in 2024 for personal care services without the required verification — in a single year, in a single state. The technology existed. The mandate existed. The verification was built. The enforcement was optional.
For ten years, the verification existed but the enforcement was optional.
In 2026, that is changing. The Company Moment this week is Texas. Not a private company. The Texas Health and Human Services Commission. The state Medicaid agency that decided to enforce verification when the federal law made enforcement optional and other states chose latitude. Texas chose strict. The fraud is now migrating away from Texas to the states still waiting. The lever exists. The lever works. Texas pulled it first.
We're not investigating the headline. We're investigating how the headline got in the room.
The verification existed. The enforcement was optional. Start with Season 2, Episode 1 for the complete arc.
SHOW NOTES — S2E5
THE COLD OPEN — OZ AT THE WHITE HOUSE PODIUM
Breitbart coverage of Oz White House press briefing, June 2, 2026
https://www.breitbart.com/politics/2026/06/02/oz-says-35-percent-of-obamacare-enrollments-may-not-be-legit/
White House press briefing transcript and video, June 2, 2026
https://www.whitehouse.gov/briefings
THE OHIO STATE AUDITOR
Keith Faber opinion piece on Medicaid fraud — Fox News, June 2026
https://www.foxnews.com/opinion/im-ohios-state-auditor-medicaid-fraud-washington-problem
Ohio Auditor of State annual audit reports
https://ohioauditor.gov
Faber Capitol Hill testimony on Medicaid fraud, June 3, 2026
https://oversight.house.gov/hearing/medicaid-fraud-investigation
THE NEW YORK COMPTROLLER REPORT
New York State Comptroller — Medicaid Personal Care Services audit, November 2024
https://www.osc.state.ny.us/audits
NY State Senate testimony on EVV implementation
https://www.nysenate.gov
DELOITTE AND THE STATE MEDICAID ELIGIBILITY SYSTEMS
KFF Health News — “Deloitte Runs State Eligibility Systems” investigation
https://kffhealthnews.org/news/article/deloitte-medicaid-eligibility-systems-investigation/
Wall Street Journal partner reporting on state Medicaid system failures
https://www.wsj.com
Tennessee Medicaid eligibility audit
https://comptroller.tn.gov
Texas HHS Medicaid eligibility federal oversight
https://www.hhs.texas.gov
ELECTRONIC VISIT VERIFICATION (EVV)
21st Century Cures Act — EVV provisions (Public Law 114-255)
https://www.congress.gov/bill/114th-congress/house-bill/34
CMS EVV implementation guidance
https://www.medicaid.gov/medicaid/home-community-based-services/guidance/electronic-visit-verification-evv/index.html
National Association for Home Care and Hospice — EVV policy positions
https://www.nahc.org
THE LEVER STATES — EVV ENFORCEMENT IN 2026
Texas HHSC Medicaid EVV program
https://www.hhs.texas.gov/services/health/medicaid-chip/medicaid-managed-care/electronic-visit-verification
Michigan Department of Health and Human Services EVV hard-edit transition
https://www.michigan.gov/mdhhs
North Carolina Medicaid EVV enforcement
https://medicaid.ncdhhs.gov
Pennsylvania DHS EVV implementation
https://www.dhs.pa.gov
IF YOU HAVE WORKED INSIDE THE SYSTEM
National Whistleblower Center
https://www.whistleblowers.org
Government Accountability Project
https://whistleblower.org
Office of Special Counsel — federal whistleblower protections
https://osc.gov
State Inspector General contacts
https://www.naoig.org
Have you ever been in a room where something shifted—but no one said it out loud?
Share your story at www.edgeofthestory.com/heard
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If we feature it, we’ll send you an Edge of the Story notebook—because some observations are worth writing down.
A Podium Line Nobody Stopped On
SPEAKER_00The administrator of the Centers for Medicare and Medicaid Services stood at a podium at the White House. The cameras were rolling, the transcript is public, the audio is on the C SPAN archive. Dr. Mehmet Oz was answering a question about fraudulent enrollments in the Affordable Care Act. He said his agency now believes that approximately 35% of current ACA enrollments may not be legitimate. Five to six million people receiving federal premium subsidies, some of them not knowing they have been enrolled. Then he said something else in the same answer. The room did not pause on it. He did not pause on it. The administrator of one of the largest payment systems in the federal government said this. He did not say the guardrails wore out. He said the agency was told to take them off. By someone. Before he arrived, in a building he is now responsible for running. He used the word told. Someone gave the instruction. That someone is not standing at the podium. That someone may have left the building years ago. That someone may still be there. That someone, whoever they were, designed a federal benefit system to operate without the verification that would normally catch fraud. And then, as the administrator said, the fraud arrived. Whether you're in your car, out on a run, somewhere in the middle of your day, or in the shop bending wire, there are moments that don't announce themselves, they don't raise their voice, they don't stop the room, but they change everything. This is Edge of the Story, Season 2, Episode 5. I'm Daryl Best. For four episodes, we have documented what happens after the guardrails come off, the autism mandate, the hospice per diem, the shell companies in Columbus, the three hundred forty B spread, different industries, different price points, same architecture. In this episode, we asked the question every episode has been building toward. Who told the agency to take the guardrails off? We're not investigating the headline, we're investigating how the headline got in the room. This season we have walked through four rooms. Each room had a word over the door Medically Necessary, end of life care, home health, safety net. Each word covered an architecture, the autism therapy provider billing $340,000 per child, the Texas hospice with the 100% live discharge rate, the $288 shell companies behind doors with no doorknobs, the Indianapolis hospital that paid $345 million in kickback settlements and kept its three hundred forty B discount the next day. Different operators, different industries, different price points, the same trust gap every time. In this episode, we go to the room behind all the rooms, where the architects who designed the systems let the operators walk through the door they design. The consulting firms paid to build them, the cabinet officials who arrived after the systems were already running, and the question the administrator of CMS asked at a White House podium two weeks ago in a single sentence that no one in the room paused on. Who told the agency to take the guardrails off?
Three Headlines On Unchecked Payments
SPEAKER_00Julia, take us to the headlines that you found this week.
SPEAKER_01Our first headline this week is from a Fox News opinion piece on the annual audit report from the Ohio State Auditor. The head Ohio State Auditor testifies that half of Medicaid home health claims bypass federally required verification. Auditor of State Keith Faber published an op-ed and testified to Congress with documented numbers from his own office's audits. Ohio invested $146 million to implement electronic visit verification. The federally required system that confirms in-home Medicaid services actually occurred before payments are processed. In 2024, roughly half of Ohio's Medicaid reimbursed home health care services skipped that required verification entirely. The agency did not enforce its own system. Federal law required it. The state built it, half the claims walked around it. Our second headline is from the New York State Comptroller Office. Its headline is New York Controller reports state paid $14.5 billion in unverified Medicaid personal care claims in a single year. The New York State Controller published a finding that in 2024 alone, New York State paid out $14.5 billion in Medicaid-funded personal care services without the required electronic visit verification confirming the services occurred. Read that number twice. $14.5 billion. One state, one year, one category of Medicaid service. Without the verification the federal government required, and the state had committed to enforce. Our third and final headline comes from Dr. Mehmet Oz in a White House briefing on June 2nd. That headline reads, CMS administrator, we took the guardrails off because we were told to.
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SPEAKER_01Mehmet Oz, the administrator of the Centers for Medicare and Medicaid services, told reporters at a White House briefing that ACA enrollment grew from 9 million people in 2015 through 2020 to over 20 million today, and that an estimated 35% of current enrollments may not be legitimate. Then he said his agency was told to remove the verification mechanisms that would have caught the fraud. He used the word told. Three headlines, three documented data points, half the home health claims in Ohio bypassed verification. New York paid $14.5 billion without verification. And the federal administrator says the system that pays both of those states was deliberately built to not verify. All sources are in our show notes.
The Firms Building Eligibility Systems
SPEAKER_00It employs over 460,000 people. Its U.S. government practice alone generates billions in annual revenue from federal, state, and local contracts. Within that government practice, Deloitte has a specialty. It builds Medicaid eligibility systems, the software platforms that determine whether a person qualifies for Medicaid, processes their enrollment, and tracks their benefits, the infrastructure on which every state Medicaid program operates. As of twenty twenty five, Deloitte operates Medicaid eligibility systems in approximately twenty five states, half the country. That includes Florida, Georgia, Pennsylvania, Michigan, North Carolina, Tennessee, Arizona, Indiana, Massachusetts, Kentucky, Virginia, Colorado, and others. The list has grown over the last 15 years through a steady accumulation of contracts, typically replacing legacy state built systems that were no longer functional, typically at a cost of several hundred million dollars per state, typically with multi-year implementation timelines and follow-on operations and maintenance contracts. The contracts are public, the names of the contractors are public, the dollar values are public. What is not public is the documented operational performance of the systems Deloitte has built.
SPEAKER_01KFF Health News, working with the Wall Street Journal and other partners, published an extensive investigation in 2023 documenting performance problems in Deloitte-built Medicaid eligibility systems across multiple states. The reporting was based on government audit reports, state legislative findings, and internal Deloitte documents. Documented findings. In Tennessee, the Deloitte-built Medicaid eligibility system erroneously terminated coverage for tens of thousands of eligible recipients. Children with cancer, adults with diabetes, people who had been on Medicaid for years and met all eligibility criteria. The state's own audit attributed the terminations to system errors in the Deloitte platform. In Texas, federal regulators warned the state about errors in its Deloitte-built system that affected eligibility determinations for hundreds of thousands of applicants. In Florida, advocates documented system failures that left disabled adults without coverage during essential medical treatment. In Kentucky, the Deloitte system erroneously approved Medicaid benefits for people who did not qualify and erroneously denied benefits to people who did. Both directions of error were documented in the state's own audit. And here's the part of the audit trail that matters most for this episode. When the systems failed, the state agencies typically did not switch vendors. They hired Deloitte to fix the systems Deloitte had built. Additional contracts, additional payments, additional billing for remediation of failures the original contract had not anticipated. The firm that built the room was hired to fix the room when the room did not work.
SPEAKER_00The existing system was built in the 1990s. It runs on outdated software. It cannot handle the application volume. Eligibility determinations take weeks. The state issues a request for proposals. Deloitte responds, so do a handful of competitors, Accenture, Maximus, sometimes Conduit or CGI. The competition is real but limited. There are only a few firms with the scale and the federal state contracting experience to bid on a three hundred million dollar Medicaid modernization. Deloitte wins. They typically win. They have the references, they have the existing relationships with federal CMS staff who must approve state Medicaid system designs. They have the playbook from the previous twenty four states they have worked in. The contract is awarded, the system is designed, the design includes verification mechanisms, some required by federal law, some required by state law, some recommended by best practice. Then implementation begins. The verification mechanisms are negotiated. Some are described as too burdensome, some are described as costly to maintain. Some are described as creating bottlenecks that would slow eligibility processing. The state agency, under political pressure to enroll people quickly, agrees to phase in some verifications and skip others. The system goes live. The verification mechanisms that were not built are not enforced. The fraud and the improper payments arrive. The state hires Deloitte to remediate. Three contracts, same firm, build the system, maintain the system, fix the system.
SPEAKER_01Here is the cleanest example we can give of how this architecture functions in practice.
EVV Mandates Built But Not Used
SPEAKER_01In 2016, Congress passed the 21st Century Cures Act. Among many other provisions, it required every state Medicaid program to implement electronic visit verification for personal care services and home health services. The requirement was simple. Before a Medicaid home health visit could be billed, the system had to confirm that a real caregiver actually showed up at the patient's home and provided the service. The verification was designed to use GPS, address confirmation, timestamps, and electronic check-in systems. The technology had existed for years. The federal mandate set a deadline. Personal care services by January 1st, 2020. Home health services by January 1st, 2023. Most states applied for good faith effort extensions. The deadline slipped. Most states built the systems eventually. Many states spent tens of millions of dollars to do so. Ohio spent $146 million on EVV. Then most states chose not to enforce the system they had built. In 2024, 10 years after the original federal mandate, Ohio audit reports documented that roughly half of Medicaid home health care claims in the state were paid without the EVV verification the system was designed to require. The system existed. The agency did not enforce it. Claims with missing or incomplete verification were paid as exceptions. The exception became the norm. In November 2024, the New York State Controller published a report documenting that New York had paid $14.5 billion for Medicaid personal care services in 24 alone, without the required verification. The state had the technology. The state had the legal mandate. The state had the contractors paid to build the system. The state did not enforce it. $14.5 billion. One state? One year, one category. Why did the states not enforce verification? Trade associations representing the home health industry. Most prominently, the National Association for Home Care and Hospice lobbied Congress and state agencies to delay implementation. They published detailed objections describing the verification as burdensome for small agencies, disruptive to workforce, and inflexible for clients with unusual care needs. Some of those objections were legitimate. Small home health agencies do face real implementation costs. Some workers in rural areas do not have reliable cell coverage to support GPS check-ins. Some patients with cognitive impairments do not understand mobile app verification. The trade association arguments were real. But the same trade associations were also receiving substantial revenue from the unverified claim streams that the legislation had been designed to constrain. Their lobbying protected both legitimate small agencies and the fraudulent operators using the same verification gap. The arguments did not distinguish between them. The verification gap protected both. Meanwhile, the firms that had built the EVV systems for the states, Deloitte among them, continued to bill annual operations and maintenance fees on systems that were not being used. The contracts paid for the technology to exist. The contracts did not require the technology to be enforced.
SPEAKER_00Now here is what is happening in 2026. In approximately 12 states this year, the EVV lever is finally being pulled. Michigan transitioned to full hard edit enforcement on January 1st, 2026. Claims with missing EVV are now rejected automatically, not paid as exceptions. Missouri followed in April. Minnesota raised its enforcement threshold from 50% to 80%. Texas now requires 80% EVV usage scores. North Carolina launched hard edit enforcement on October first, 2025. Pennsylvania, Wisconsin, Indiana, and several others are implementing the same transition. The documented operator costs are real. Small home health agencies face implementation expenses they had been allowed to avoid for ten years. Some agencies will not survive the transition. Some legitimate workers will lose jobs because their employers cannot adapt. Cash flow disruption is genuine. The trade association warnings about burden were not entirely wrong. And the documented results from the states that have already pulled the lever are also real. Claim volumes have dropped, fraudulent operators have closed, patient verification rates have climbed. The lever exists, the technology works, the federal government required it ten years ago. The states built it, the agencies are finally enforcing it. Some states are pulling the lever first, others are still waiting. And the fraud is migrating from the states that pulled the lever to the states that have not.
SPEAKER_01Here is the architecture stated cleanly. The lever was built, the lever was funded, the lever was required by federal law. The lever was not pulled for 10 years. The reason it was not pulled is not technological. The reason is not financial. Was an architecture in which the verification existed, but enforcement was optional. The verification existed because the law required it. The enforcement was optional because the architecture allowed it. That is the answer to the question we started with. Who told the agency to take the guardrails off? The answer is that the guardrails were taken off the same way every other architecture this season has been built. Not by a single bad actor, not by a conspiracy, by a system of incentives in which the consulting firms profit from complexity, the agencies profit from enrollment numbers, the trade associations profit from unverified claim streams, and the cabinet officials profit from the press conferences that arrive when the fraud is eventually announced. Nobody had to give the instruction directly. The architecture issued the instruction by being the architecture. The verification mechanism existed, but enforcement was optional. The patient was on the books, but the visit did not have to happen. The hospital was a safety net, but the spread did not have to fund charity care. The autism diagnosis triggered reimbursement, but the therapy did not have to work. Same architecture, different room, five episodes, one answer.
Texas Pulls The Enforcement Lever
SPEAKER_00Our company moment this week is about a state that pulled the lever before the others.
SPEAKER_01Texas was not the first state to require electronic visit verification. Texas was not the loudest about it. Texas does not get the headlines that California and New York and Florida get when fraud or reform makes the news. But Texas was one of the first states to require an 80% EV usage score from home health providers as a condition of Medicaid payment. The Texas Health and Human Services Commission, the state agency that administers Medicaid in Texas, issued the requirement, set the threshold, and applied it across the home health system. The 80% threshold means this. If a home health agency cannot demonstrate that at least 80% of its visits were verified through the EVV system, the agency is subject to a corrective action plan. If the corrective action plan does not produce compliance, payments are suspended. The agency is held accountable for proving the visits actually occurred. That sounds simple. It is not. Implementing it required Texas to make a series of decisions that other states had been avoiding for years. Texas had to choose to enforce a federal requirement that was technically optional. The 21st Century Cures Act required states to implement EVV, but provided latitude on how strictly to enforce it. Texas chose strict. Other states chose latitude. Texas had to absorb political pressure from the home health industry. The Texas Association for Home Care and Hospice opposed parts of the enforcement framework. They documented legitimate concerns about implementation costs for small rural agencies. The state listened to those concerns, made some accommodations, and did not back down on the 80% threshold. Texas had to invest state staff time in compliance monitoring. EVV enforcement is not free. It requires Medicaid agency personnel to review provider compliance rates, issue corrective action plans, and follow up on noncompliance. That is real budget. That is real political cost when staff time could have been allocated to other programs. Texas did it anyway.
SPEAKER_00Here is what this company moment is and is not. It is not a story about Texas being better than other states at running health care. Texas has its own documented Medicaid problems. Texas has not solved every fraud or every coverage gap. Texas has its own contracts with the same consulting firms and its own architectural compromises. What Texas did with EVV was choose to enforce something the architecture made optional. Other states with the same federal requirement and the same vendor contracts and the same trade assignments. Association Pressure made a different choice. They chose latitude. They paid the billions in unverified claims. They are now playing catch up while Texas operates at 80% verified. That choice has consequences for real people. Patients who actually need home health services in Texas are more likely to receive them because the verification system flags the agencies that bill without delivering care. Workers in Texas home health agencies are paid because their visits are documented. Taxpayers in Texas absorb fewer fraudulent claims. And the fraud that used to operate in Texas home health is migrating to states with weaker enforcement. The architecture does not disappear when one state tightens its rules. The architecture moves to the next state where the rules are still optional. CMS administrator Oz documented this pattern with hospice fraud moving from California to Texas. The same migration is happening with home health fraud in the opposite direction. From Texas where the lever was pulled to states where the lever is still in the box. This is what an outside the architecture choice looks like at the state government level. Not a private company building a parallel pharmacy, not a founder writing a cold email to twenty-seven billionaires. A state Medicaid agency that decided to enforce the federal law on its books, even though the architecture made enforcement optional, even though the trade associations objected, even though the lobbying pressure was real, even though no other state was pulling the lever first. Texas chose to use the lever, the lever worked. That is the American spirit applied to public administration. Not waving a flag, not making a speech, just deciding to enforce the rules that were already on the books, deciding to make the system do what the system was designed to do.
The Meeting Where Delay Wins
SPEAKER_00If you have ever worked inside a government agency or government funded contractor, you have probably been in the meeting this episode describes. The meeting where someone says we should turn on the verification, but someone else says we will if we have time. The meeting where the consulting firm describes the burden as too high. The meeting where the trade association representative cites the small rural agency that cannot afford the technology. The meeting where the senior official decides to phase in the requirement and revisit it in twelve months. Twelve months becomes eighteen. Eighteen becomes three years. Three years becomes a decade. The verification is in the system. The enforcement is on the shelf. Nobody decided to take the guardrails off. Everyone made a small, reasonable compromise. The compromises accumulated. The guardrails were there, just not installed. If you have been in that meeting, we want to hear from you. Not for accusation, the quiet witness. Or maybe the opposite. Maybe you were the person in the meeting who said, let's turn it on now. Let's enforce the threshold, let's actually verify. And you watch the room slow walk you, you watch the consulting firm bill another twelve months of analysis, you watch the legislator who had championed the verification get reassigned to another committee. You watch the architecture defend itself. Both stories matter. The architecture is not invincible. The states that pulled the lever this year prove that. But pulling the lever required someone somewhere inside the system to keep saying the same thing in the same meetings for years. Most of those people are not at the press conference. Most of them are still in the building. Find us at edge of the story dot com slash heard. We read everything. The most important stories of the season are coming from the listeners who have been in the room. Five episodes in, halfway through the season. We have walked through five rooms. Each one had a word over the door. Each one had an architecture behind it. Each one had a cost paid by someone who was not at the table when the word was chosen. Medically Necessary and a life care home health safety net. And tonight the system. Five words, one architecture, five episodes. And in every episode, the same kind of story keeps appearing outside the architecture. Dr. Doreen Grampiche, starting card with one clinic in 1990. Bob McNutt at the Collins Street Bakery learning to double check after the embezzlement. The investigator who walked the hallway in Columbus and found the missing doorknob. Dr. Alex Oshmiansky cold emailing 27 billionaires to fund a transparent pharmacy. The architecture is built by institutions, the exits are built by individuals, and the individuals are not always private actors. Sometimes the individuals are inside the system doing the slower, harder work of making the system do what it was designed to do. Next week we go to a different industry, same architecture, new word, behavioral health, the treatment centers that have been rolled up by private equity over the last decade, the reimbursement structure that pays for evidence-based treatment but does not require the treatment to be evidence-based, the Florida clinic chains that bill commercial insurance for therapy protocols whose evidence base is contested or absent. The patients in their most vulnerable moments, in recovery from addiction, in mental health crisis, enrolled in programs that exist primarily as billing operations, same architecture, different word, different price tag, same trust gap. Episode six opens the second half of season two. Next week on Edge of the Story.
Share The Story And Next Week
SPEAKER_00The word that covered the diagnosis, not the patient, not the treatment, just the word that opened the billing code. Edge of the Story is produced high atop Chalk Mountain. If the gate is open, stop in and we'll chat a while. If this episode changed how you hear the word system, share it. Share it with someone who works inside one. With someone who has watched a verification mechanism get phased in and never turned on. With someone who has been in the meeting where everyone agreed to revisit it in 12 months. Every source is in our show notes. The Ohio Audit Reports, the New York Comptroller Report, the KFF Health News Investigation, the Cures Act language, every name, every number, every filing. We don't hide our work. We're not investigating the headline, we're investigating how the headline got in the room. See you next week.