Medicaid managed care serves 86 million beneficiaries at 376 billion annually, yet evidence that managed care delivery improves outcomes remains inconclusive, with nearly 40% of Medicaid acute care visits attributable to ambulatory care-sensitive conditions. State procurement processes create principal-agent relationships where managed care organizations (MCOs) make performance commitments before contract award, but no research has systematically evaluated whether MCO commitments align with state priorities. We assembled 265 procurement documents from 32 states (2017-2024), extracting 1666 text files. Using retrieval-augmented generation (a method that grounds AI outputs in retrieved document passages) with large language model analysis, we extracted 372 283 performance claims classified into 6 thematic domains. Two doctoral-level coders validated a stratified random sample (Cohen's kappa: 0. 86, 95% CI: 0. 81-0. 91). We calculated per-file normalized concordance ratios (MCO claims per document divided by state requirements per document, controlling for document volume) and conducted stratified analyses by document type. MCOs systematically overemphasized technology claims (normalized concordance ratio: 53. 9, median: 28. 2) and health equity claims (ratio: 22. 0, median: 10. 3) relative to state requirements, while underemphasizing chronic disease management (ratio: 15. 8) and workforce development (ratio: 14. 2). Post-pandemic increases in health equity (10. 3-fold) and technology claims were driven primarily by state contract and scoring documents rather than MCO proposals. Only 6 states had sufficient paired data for concordance analysis. Medicaid procurement documents reveal systematic thematic divergence between MCO performance claims and state priorities. The observed patterns may reflect strategic positioning, normal negotiation dynamics, or evolving state procurement frameworks. Given that Medicaid beneficiary outcomes remain poor despite widespread managed care adoption, procurement reforms requiring measurable, time-bound performance commitments could improve alignment between organizational claims and care delivery. Short Article Summary - Layperson TermsWhen states hire insurance companies to manage Medicaid health coverage for low-income Americans, the companies make extensive promises about what services they will provide, but this study found they systematically overpromise on politically popular topics like technology and health equity while undercommitting to everyday care like managing diabetes or having enough doctors in their network. States should require insurance companies to back up their promises with specific numbers and deadlines rather than accepting vague commitments that sound good but don't translate into better care for the ~80 million Americans who depend on Medicaid.
Basu et al. (Sun,) studied this question.