The structure of Medicaid almost guarantees this outcome. Federal matching funds create an incentive where states get more money by spending more — not by spending well. Oversight is split across federal and state lines so no single entity owns accountability. When you design a trillion-dollar system where the reward mechanism is volume rather than verification, fraud isn't a bug. It's the predictable output of the incentive architecture. The fact that it took independent journalism to surface this says something about where institutional oversight actually sits.