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Jose Nu帽ez, a Los Angeles truck driver, sought help from his Medicaid plan, a California unit of Centene, the nation鈥檚 largest Medicaid insurer, after he developed an infection in his right eye related to diabetes. (Heidi de Marco/KHN)

With no insurance through his job, Jose Nu帽ez relied on Medicaid, the nation鈥檚 public insurance program that assists 75 million low-income Americans.

Like most people on Medicaid, the Los Angeles trucker was assigned to a private insurance company that coordinated his medical visits and treatment in exchange for receiving a set fee per month 鈥� an arrangement known as managed care.

But in 2016, when Nu帽ez鈥檚 retina became damaged from diabetes, the country鈥檚 largest Medicaid insurer, Centene, let him down, he said. After months of denials, delays and erroneous referrals, he claimed in a , the 62-year-old was left nearly blind in one eye. As a result, he lost his driver鈥檚 license and his livelihood.

鈥淭hey betrayed my trust,鈥� Nu帽ez said, sitting at his kitchen table with his thick forearms folded across his chest.

The current political debate over Medicaid centers on putting patients to work so they can earn their government benefits. Yet some experts say the country would be better served by asking this question instead: Are insurance companies 鈥� now receiving hundreds of billions in public money 鈥� earning their Medicaid checks?

More than two-thirds of Medicaid recipients are enrolled in such programs, a type of public-private arrangement that has grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act.

States have eagerly tapped into the services of insurers as one way to cope with the expansion of Medicaid under the ACA, which has added 12 million people to the rolls. This fall, voters in three more states may pass ballot measures backing expansion. this public program to insurers has become the preferred method for running Medicaid in 38 states.

Yet the that these contractors improve patient care or save government money. When auditors, lawmakers and regulators bother to look, many conclude that Medicaid insurers fail to account for the dollars spent, deliver necessary care or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to shell out money.

鈥淲e haven鈥檛 been holding plans to the level of scrutiny they need,鈥� said Dr. Andrew Bindman, former director of the federal Agency for Healthcare Research and Quality and now a professor at the University of California-San Francisco. 鈥淭his system is ripe for profit taking, and there is virtually no penalty for performing badly.鈥�

In return for their fixed fees, the private insurers dole out treatment within a limited network, in theory allowing for more judicious, cheaper care. States contract with health plans as a way to lock in some predictability in their annual budgets.

More than Medicaid recipients are now covered by managed-care plans, up from fewer than 20 million people in 2000. (In traditional Medicaid, states pay doctors and hospitals directly for each visit or procedure 鈥� an approach that can encourage unnecessary or excessive treatment.)

Already, states funnel nearly annually to Medicaid insurers. That鈥檚 up from $60 billion a decade ago. Today鈥檚 spending is approaching what Pentagon awards annually to contractors.

Jose Nu帽ez says he and daughter Diana Nu帽ez took turns calling his Medicaid plan and waiting on hold for answers after his eye surgery was canceled twice. He waited three months for his insurer to approve the operation, he says. By that time, his retina had deteriorated and Nu帽ez was nearly blind in one eye.(Heidi de Marco/KHN)

Medicaid is good for business: The stock price of Nu帽ez鈥檚 insurer, Centene, has soared 400 percent since the ACA expanded Medicaid eligibility. The company鈥檚 chief executive took in $25 million last year, the highest pay for any CEO in the health insurance industry. In California, the largest Medicaid managed-care market with nearly 11 million enrollees, Centene and other insurers made $5.4 billion in profits from 2014 to 2016, according to a Kaiser Health News analysis.

Plans get to keep what they don鈥檛 spend. That means profits can flow from greater efficiency 鈥� or from skimping on care and taking in excess government payments.

鈥淪tates are just giving insurers the keys to the car and a gas card,鈥� said Dave Mosley, a managing director at Navigant Consulting and former finance director at the North Carolina Medicaid program. 鈥淢ost states haven鈥檛 pressed insurers for the information needed to determine if there鈥檚 any return on their investment.鈥�

Two of California鈥檚 most profitable insurers, Centene and Anthem, ran some of California鈥檚 worst-performing Medicaid plans, state quality scores and complaints in government records show. California officials have been clawing back billions of dollars from health plans after the fact.

For nearly two decades, federal officials have tried building a national Medicaid database that would track medical care and spending across states and insurers. It鈥檚 still , hampered by differing state reporting methods and refusals by some health plans to turn over data they deem trade secrets.

In July, a federal inspector general鈥檚 report accused Medicaid insurers of purposefully ignoring fraud and overpayments to doctors because inflated costs can lead to higher rates in the future.

In a report last month, the U.S. Government Accountability Office disclosed that California鈥檚 Medicaid program is unable to electronically send records justifying billions of dollars in spending, forcing federal officials to sift through thousands of documents by hand. California said it can鈥檛 share key files electronically because it uses 92 separate computer systems to run the program.

鈥淵ou simply cannot run a program this large when you can鈥檛 tell where the money is going and where it has been,鈥� said Carolyn Yocom, a health care director at the GAO.

Today, Medicaid consumes the single-largest share of state budgets nationwide at nearly 30 percent 鈥� up from less than 21 percent a decade ago 鈥� crowding out funding for education, roads and other key priorities.

鈥淚f anything, our results suggest that the shift to Medicaid managed care increased Medicaid spending,鈥� researchers at the Congressional Budget Office and the University of Pennsylvania concluded in 2013, based on a .

Industry officials insist that managed care saves money and improves care. Medicaid Health Plans of America, an industry trade group, points to a showing that health plans nationally saved the Medicaid program $7.1 billion in 2016.

Health plans also say they can help modernize the program, created more than a half century ago, by upgrading technology and adopting fresh approaches to managing complex patients.

Getting it right has big implications for patients and taxpayers alike, but the results in many states aren鈥檛 reassuring.

State lawmakers in , both Republicans and Democrats, criticized their Medicaid program last year for ignoring the poor performance of two insurers, UnitedHealthcare and Centene, even as the state awarded the companies new billion-dollar contracts.

In Illinois, the state didn鈥檛 properly monitor $7 billion paid to Medicaid plans in 2016, leaving the program unable to determine what percentage of money went to medical care as opposed to administrative costs or profit.

In April, Iowa鈥檚 state ombudsman said Medicaid insurers there had denied or reduced services to disabled patients in a 鈥溾�� way. In one case, an insurer had cut a quadriplegic鈥檚 in-home care by 71 percent. Without the help of an aide to assist him with bathing, dressing and changing out his catheter he had to move to a nursing home, according to the ombudsman, Kristie Hirschman.

鈥淲e are not talking about widgets here,鈥� Hirschman said. 鈥淚n some cases, we are talking about life-or-death situations.鈥�

Meanwhile, the Trump administration has sent mixed signals on Medicaid oversight. Seema Verma, administrator for the Centers for Medicare & Medicaid Services, has promoted a new, nationwide scorecard and vowed to ramp up audits targeting states and health plans.

鈥淲e need to do better,鈥� Verma said in a to the Medicaid managed-care industry. 鈥淢edicaid has never developed a cohesive system of accountability that allows the public to easily measure and check our results.鈥�

But consumer advocates also are concerned that Verma鈥檚 efforts to roll back 鈥溾�� will weaken accountability overall. Many also disagree with her support of Medicaid work requirements.

Nu帽ez, the truck driver who lost much of his sight, is suing a unit of Centene for negligence and breach of contract. The company has denied the allegations in and declined to comment further, citing the pending .

Talk of requiring Medicaid recipients to work is hard for him to take. 鈥淚 need my health to work,鈥� he said. 鈥淭hey took that away from me.鈥�

This story was produced by聽, which publishes聽, an editorially independent service of the聽.