Looking at these plans as akin to general contractors for the healthcare system, especially for the poor and states, it's a low-margin business. Is there any reason why margins over the next 10 years should differ significantly from the last 10 years? Given the push and pull, plans need enough payment to cover costs and make a profit, while states aim to pay as little as possible. This tension has always existed. Should the balance change over time?

From both a political and social standpoint, I don't see how it can be different. We struggle because providers make more money on commercial insurance, which is their biggest revenue source. Then there's Medicare, and Medicaid is the least profitable. I see fewer providers willing to accept Medicaid. They often say they don't want to take it at all. Without interventions, like forcing providers to accept both Medicare and Medicaid, or some other government interference, it will be harder to establish provider networks. When that happens, it squeezes the profit margin. A smaller network allows providers to demand higher payments due to lack of competition. So, I don't see the margins really changing.