Agree States should fund (at least the majority) of Medicaid costs and administer their own benefits. Frankly since we have such a political divide in this country we should push more benefits and laws out to the states and let their residents and voters determine such things. As for the risk money holder, I much prefer to have a private insurance company that has to compete for my business and satisfaction as the provider over the government. If I'm unhappy with the service I get from my insurance company, I (or their collective customers) can scream bloody murder and/or take my business elsewhere to get results. If you're unhappy with the government as the gatekeeper, leverage is nil and unfortunately my life experiences with government overwhelmingly support this view.