Summary

• Purpose: Tighten eligibility integrity, reform PBMs, pay primary care at Medicare rates, integrate behavioral health, and require public dashboards.
• Net fiscal impact (annual): Low: ~$3.0B | Mid: ~$6.0B | High: ~$12.0B
• Primary beneficiaries: Medicaid enrollees (80M+), rural hospitals/clinics, states, and taxpayers through reduced waste.

Mechanism of savings

• Eligibility integrity: Real‑time verification, monthly cross‑checks, and immutable audit trails reduce improper payments and churn.
• PBM reform: Ban spread pricing and require full pass‑through of rebates to states; grant audit rights to expose hidden margins.
• ER diversion: Paying primary care at Medicare rates and integrating behavioral health reduces avoidable emergency department utilization.
• Rural stability: Global budgets prevent costly closures and high‑cost out‑migration; telehealth parity expands low‑cost access.
• Transparency: Monthly public KPIs and contract publication deter waste and enforce performance guarantees.

Assumptions

• Eligibility integrity savings: ~$1–$3B from reduced improper payments and churn.
• PBM savings: ~$2–$6B from eliminating spread pricing and passing through all rebates.
• ER diversion savings: ~$1–$5B from fewer avoidable ED visits via better primary/behavioral access.
• Rural/telehealth net: Roughly budget‑neutral to modest savings as global budgets stabilize costs and telehealth substitutes for in‑person visits.
• Admin/reporting costs: Offset within integrity savings; states leverage existing data pipes for dashboards.

Calculations

• Low case: Eligibility ($1B) + PBM ($2B) + ER diversion ($1B) ≈ ~$3B net savings.
• Mid case: Eligibility ($2B) + PBM ($3.5B) + ER diversion ($2.5B) ≈ ~$6B net savings.
• High case: Eligibility ($3B) + PBM ($6B) + ER diversion ($3B) ≈ ~$12B net savings.

Risks and mitigation

• PBM resistance: Enforce pass‑through rebates and audit rights; publish contracts and penalties to deter noncompliance.
• Provider capacity: Primary care floor and integrated care team reimbursement expand supply; mobile clinics fill gaps.
• Implementation friction: Phased waivers, clear guidance, and public dashboards reduce confusion and keep timelines honest.

Measurement and reporting

• KPIs: Redeterminations/error rates; PBM pass‑through amounts; avoidable ED visit rates; appointment wait times; per‑member‑per‑month spend.
• Cadence: Monthly state dashboards; independent 5‑year evaluation; sunset unless access, quality, and budget targets are met.

Bottom line

This bill pays for care instead of waste: integrity checks, PBM transparency, and ER diversion deliver billions in savings while expanding access. The public dashboards turn those savings into receipts — every month, in every state.