Breaking: Craig Garthwaite’s new healthcare blueprint lands today with a blunt message for Congress and the states. Coverage is not the same as care. As lawmakers fight over expiring ACA premium subsidies, his plan targets a different problem, the daily struggle Medicaid patients face to get an appointment, a diagnosis, and a plan that actually helps.
What Garthwaite Puts On The Table
I reviewed the policy paper, Coverage Isn’t Care, released with the Aspen Economic Strategy Group. It zeroes in on Medicaid, which covered about 78 million people as of December 2024. The thesis is simple. We fight over who pays, but we ignore how much care a dollar buys, and whether patients can even get through the door.
Garthwaite’s core proposals are practical and direct:
- Loosen licensing barriers so more internationally trained doctors can practice
- Expand autonomy for nurse practitioners and physician assistants
- Deploy AI-augmented care models to lower costs and free up clinician time
The point is not to lower standards. It is to raise access. Many Medicaid patients cannot find a provider who accepts their plan. Garthwaite argues that the workforce is too small, the rules are too tight, and technology is underused.
The Legal Stakes For Medicaid And The States
The plan targets the legal chokepoints that limit supply. State medical boards control licensing. State law defines scope of practice for nurse practitioners and PAs. Those rules vary widely. In full practice states, nurse practitioners can diagnose, treat, and prescribe on their own. Other states require doctor supervision. Easing those limits would expand basic care, especially in rural and low income areas.
There is a federal hook too. The Medicaid Act requires states to keep payment and access at levels that are consistent with efficiency and quality of care. That is Section 1902(a)(30)(A). Patients cannot easily sue states to enforce that clause, after the Supreme Court’s Armstrong v. Exceptional Child Center ruling. But the federal government can still act through oversight and funding conditions.
Medicaid managed care has network standards as well, under 42 CFR 438.68. Those rules require states to ensure plan networks are big enough. If networks fail, states risk corrective orders, penalties, or a loss of federal funds.
The ACA premium subsidies are set to lapse at year end. Even if Congress extends them, the access crisis in Medicaid will not fix itself without supply side action.
How Congress And CMS Could Move Now
Congress could greenlight more global medical talent. That means faster visas, more residency slots, and provisional licenses tied to supervised practice. Lawmakers could build on existing J-1 waiver tools and the Conrad 30 program. States could allow supervised pathways for qualified international doctors who do not have a U.S. residency, with clear guardrails.
CMS can also pull levers quickly. Section 1115 waivers let states test new ways to deliver care. CMS could prioritize waivers that expand scope of practice, increase primary care pay for Medicaid, and pilot AI-enabled triage and follow up tools. The agency can also tighten network adequacy enforcement and link federal matching funds to real access gains.
AI raises special legal questions. Tools that guide clinical decisions may face FDA oversight. Data use must comply with HIPAA and state privacy laws. Health systems will need clear rules on liability, disclosure, and fairness.
AI tools that explain their logic and allow clinician override are less likely to be regulated as medical devices. But oversight can still apply depending on how the tool is used in care.
Risks, Rights, And The Road Ahead
Big reforms meet big resistance. Physician groups may oppose broader autonomy for nurse practitioners. Medical boards may resist new licensing pipelines. Hospitals may worry about liability for AI mistakes. Medicaid pay rates remain low, which can limit provider participation even if rules change. These barriers are real.
Still, the legal path exists. States control licensing and scope. Congress can back workforce growth. CMS can reward access, not paperwork. If pay aligns with outcomes, and if the workforce grows, Medicaid patients can see and feel the change.
Medicaid beneficiaries should also remember their rights. Children have a federal right to timely screenings and treatment through EPSDT. All patients are protected from discrimination under Section 1557 of the ACA. Managed care plans must meet network standards. If you cannot get a timely appointment, you can file a grievance with your plan and a complaint with your state Medicaid agency.
If you are denied timely care, document calls and dates, ask for the plan’s grievance process, and escalate to your state’s Medicaid ombudsman. Keep copies. Deadlines matter.
Frequently Asked Questions
Q: Does this plan replace the ACA?
A: No. It focuses on Medicaid access and efficiency, not the ACA marketplace design.
Q: Will easing licensing lower quality?
A: The plan calls for clear guardrails, supervised entry, and data tracking. It aims to expand safe access, not cut corners.
Q: Can states act without Congress?
A: Yes, on scope of practice and certain licensing steps. Federal changes can speed visas, boost residencies, and support pilots.
Q: Is AI in care legal today?
A: Yes, with limits. Privacy, safety, and liability rules apply. Systems must be tested, transparent, and supervised by clinicians.
Q: What rights do Medicaid patients have on access?
A: Plans must have adequate networks. Children get EPSDT benefits. You can file grievances and state complaints if access fails.
Garthwaite’s blueprint offers a middle path. It keeps the insurance frame, then fixes the bottlenecks that block care. The legal tools are ready. The clock is ticking. Now it is a test of will, not ideas.
