The state contracted management of Medicaid out to private managed care companies in two stages, in 1994 and 2009, and the managed care plans are now imposing so many restrictions on formularies and prior authorizations that caring for Medicaid patients means spending much of the day, and hiring extra staff, to jump through hoops to get patients the care they need. This is MUCH worse now than it was a few years ago, and doctor acceptance of new Medicaid patients has declined markedly as a result. It is the private managed care plans that are spending the Fed's money with no accountability.