Memetic Literacy Checklist Onepager

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The point of the checklist is to slow your reaction down long enough to read what is actually in front of you.

Part One: Four Signs of a Memetic Attack

1. From 0 to 60 in 4.3 Seconds

A target who has been writing or working in a sensitive area for years suddenly experiences a surge of attacks across multiple platforms within hours of a specific piece, vote, or finding. Look at the accounts. Are they organic readers — people with posting histories that pre-date the controversy and span topics? Or freshly created profiles and accounts whose only activity is this campaign? Are a small number of high-reach hubs amplifying a long tail of smaller accounts that don't seem to know each other?

2. Personal, not substantive

Read the actual content. Does it engage the underlying claim, or does it go after their character, mental state, family, finances, or sexuality? A campaign concerned with truth argues about facts. A campaign concerned with reach goes after the person.

3. The Phrase Repeats across accounts

Watch for recyclable language: "discredited," "unhinged," "disqualifying," "everyone knows," "long-known issues." When the same phrase appears across accounts that have no organic connection to each other, you are usually looking at supplied vocabulary, not independent observation. Two years later, a journalist who has never heard of the campaign will type the target's name into a search bar and find the phrase staring back.

4. Institutional Response Lags

Platforms, prosecutors, and editors are slow to react because each individual post is, in isolation, defensible as opinion. The coordinated effect is illegible to systems that adjudicate one post at a time. The absence of a moderation response is not evidence the attack is legitimate. It is evidence the moderation system is structurally outmatched.

Part Two: Habits that Protect You

5. Read the Source Document

If the target wrote something, find it and read it. If they voted on something, look up the bill. If they were charged with something, read the indictment or the court filings. The commentary about a person's work is the cheapest content to produce; the work itself is where the facts live.

6. Locate the Origin

When you encounter a damning characterization, ask where it came from. Trace it back as far as you can. If the trail dead-ends in a single anonymous account, a deleted post, or a publication with no editorial accountability, weigh the claim accordingly. If it traces back to a credentialed source whose record stands up — court documents, peer-reviewed research, an inspector general report — also weigh it accordingly.

7. Read the Campaign, not the Target

When you see a sudden flood of identical phrasing, you are receiving data — but it is data about the campaign, not about the target. The coordinated nature is the story. Sometimes the campaign is also correct on the merits, but it often is not. Treat the questions separately.

8. Weigh Formal Accountability Findings

Nobel committees, inspectors general, federal courts of appeal, peer-reviewed analyses, and licensed professional bodies are slow, imperfect, and sometimes captured. They are still, on average, a better signal than volume on a platform. When a formal finding contradicts the social-media consensus, that is information worth taking seriously — in either direction.

What Not to Do

When you spot a campaign you believe is unjust, it is tempting to fight back online. Operators plan for this, and any volume feeds their algorithm. Memetic attacks are designed for short-term narrative. Information gathering is unglamorous and demanding. It is the work over time that defeats the short-term narrative.

The single most useful thing a reader can do is keep learning, reading, and paying attention. The information doesn’t, by itself, defeat disinformation. But the accountability work depends on engagement. It is the long-term work of life that defeats the short-term story driven by these platforms.

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Sarah Unsicker is a former Missouri legislator who writes about policy and legislative craft from the concept to the courtroom.

Accountability work depends on an information environment that is being actively degraded. Much of the degradation is aimed at the exact function accountability requires: your ability to tell what is true.

You cannot hold a regulator, a legislator, or an agency to account if you cannot first trust your own reading of the record. This series is about the mechanics of the attack, the habits of mind that resist it, and the institutions that are supposed to help but keep arriving late.

Caution:

I want to tread lightly here. The topic invites overstatement. Hyperbole, cynicism, and disengagement are the targets of the degradation work. It is not about what you think, but whether you think at all. Not everything is disinformation. Criticism can be genuine and still push its readers into the trap.

I am here to give you tools.

There are recognizable techniques for making a credible source look untrustworthy. Those techniques are cheap and widely deployed, and the defense against them is a set of reading habits that any citizen can learn. The work is not glamorous, but it is where the truth hides.

How the Pieces Fit Together:

The mechanics

When the Meme Is the Weapon walks through Maria Ressa's case, the cleanest documented example of a coordinated social media campaign built to make an accountability journalist radioactive as a source. Roughly sixty percent of the online attacks on her had nothing to do with her reporting. That is the tell, and the pattern repeats at every level of governance where someone with a record is in the way of someone with a platform.

The Foundation

Orwell (forthcoming): Orwell's standing warning was never really about a particular regime; it was about a public's willingness to detach language from the world it is supposed to describe. "Two plus two make four" is the whole discipline in miniature: the refusal to round the answer, to accept agentless fog where named actors belong, to let the record be quietly rewritten.

The Institutional Gap

I will discuss why the systems that are supposed to catch this reliably miss it. The short answer is structural: each individual post is defensible in isolation, so a coordinated campaign is illegible to any system that adjudicates one post at a time. Understanding that gap is the difference between expecting institutions to save us and knowing where we have to cover for them.

The Reader’s Tool

A Citizen's Memetic Literacy Checklist is the reader's tool for this series: four signs you're watching a coordinated reputation attack, and four habits that keep you sane. If you keep only one thing from this thread, keep this one — it's built to be printed, shared, and pulled up mid-scroll, and a printable one-pager is attached to it.

Memetic Literacy Checklist Onepager

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A closing note on why this sits inside an accountability publication rather than a media-criticism one. Everything I write here — from Medicaid integrity to legislative craft, from concept to courtroom — assumes a reader who can still be reached by evidence. That assumption is not safe anymore, and pretending otherwise would make the rest of the writing dishonest. So this series is, in a sense, the maintenance work underneath everything else: keeping the channel open.

Memetic warfare wins when we trust the meme more than the work. The defense, such as it is, runs through the reader. If that is the job you signed up for, you are in the right place.

Sarah Unsicker is a former Missouri legislator who writes about policy and legislative craft from the concept to the courtroom.

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This week I want to follow that thread into a courtroom, because something landed on the Cole County docket on June 18 that states the principle I was circling — states it cleanly, formally, with citations — and then aims it in exactly one direction.

The case is Schappe, Inc. d/b/a Tuners Bar & Grill v. Catherine L. Hanaway, Missouri case 26AC-CC00337, a proposed class action against the Missouri Attorney General in her official capacity. The subject is gray-market gaming machines: the “pre-reveal” amusement devices that have hummed away in Missouri gas stations, bars, and fraternal halls for more than a decade. The Attorney General has launched an enforcement campaign against them — search warrants, seizures, felony charges in some counties, misdemeanors in others, demand letters from municipal police giving operators until a deadline to unplug. The plaintiff hasn’t been charged with anything. It is suing to stop the campaign before it arrives.

I have no particular brief for the gambling machines. Whether Missouri should license them, tax them, ban them, or leave them alone is a question for the legislature, and the legislature — as the petition correctly notes — has looked at the question repeatedly and declined to answer it. That silence is the whole point.

What interests me is the constitutional argument the plaintiff makes, because it is, almost word for word, the grievance I have been writing about from the other side of the glass.

The petition’s theory is this: a criminal statute that no one can read in advance to know what it forbids — whose practical scope is set not by the legislature but by which cases a prosecutor decides to bring — is not really a law at all. It quotes Justice Gorsuch: vague laws “leave people in the dark about what the law demands and allow prosecutors and courts to make it up,” and “in our constitutional order, a vague law is no law at all.” It argues that when the same statute, unchanged in text for decades, gets enforced one way in one county and the opposite way in the next, with “no intervening legislative amendment, no intervening appellate ruling, and no published regulation,” what you have is not the rule of law but the rule of whoever holds the office that week. It argues that a rule whose meaning “shifts with the identity of the Attorney General in office” has “ceased to function as law” and “become a license.”

Read that last line again. A rule that has become a license. Strip out “Attorney General” and “statute,” and you have a precise description of how a political caucus disciplines a member. The text never changes. The application does — depending on who you’ve crossed, what moment it is, and whether anyone with standing decides to make an example of you. There is no published standard for what gets you removed from a caucus or stripped of a committee or quietly told you are no longer welcome at a club meeting. There is no notice. There is no appellate court. There is, to borrow the petition’s own framing, a standardless sweep that “allows policemen, prosecutors, and juries to pursue their personal predilections” — except the actors are party officers, and the forum is a meeting room, and the Constitution has nothing to say about it.

I want to be careful here, because the point is not that the lawsuit is wrong. The vagueness doctrine is real and important, and the argument the petition makes is a serious one — serious enough that I think the businesses bringing it have a genuine constitutional grievance about being threatened with felonies for conduct the legislature never plainly criminalized. The doctrine deserves to win when the state tries to manufacture crimes by enforcement. That is exactly what it is for.

The point is the asymmetry. The principle that the state may not punish you under a standard too vague to know in advance, may not single you out by discretion for conduct it tolerates in others — that principle is available, with a filing fee and a good lawyer, to a bar in St. Charles defending its slot-adjacent machines. It is not available to a member of a political body subjected to the informal version of precisely the same thing. The machines get a forum. The person does not.

Consider what that informal version looks like in practice, because I served alongside it.

I wrote last time about Bob Burns — the St. Louis County Democrat whose warm on-air calls to a racist radio host surfaced in April 2018, at the precise moment the caucus had a Republican governor on the ropes. What I described then as a matter of timing was also, up close, a matter of discipline. Within a day of the recordings going public, the Minority Leader stripped Burns of his committee assignments. Within weeks, the caucus voted to expel him from its ranks. Burns had broken no written rule — he never used a slur himself; he had praised a man who did — and he was given no notice, no hearing, and no appeal. There was a leadership decision and a caucus vote, and that was the entire process. He kept his seat anyway, running unopposed that November. The caucus could remove him from itself; it could not remove him from the ballot.

And it is not a relic of one chaotic spring. In May 2025, the same caucus stripped Representative Marlene Terry — a Black woman representing north St. Louis County — of all four of her committee assignments, including her ranking position on the Legislative Review committee. Her offense was a vote: in a budget conference she had sided with the Republican governor on how to fund education, after backing a school-choice bill the year before. Leadership did not like the vote, so it took the committees. “I don’t have to be in a committee to be heard,” Terry told the House floor. “I will vote how I please, when I please and where I please. No one can take away my voice.” She was right that they could not take her voice. They could, and did, take everything that was theirs to grant and revoke at will — which is the whole point. The operative standard was loyalty, and loyalty is not a standard anyone can read in advance.

I raise these not to relitigate either episode, but because the petition now on the Cole County docket comes from inside that same political world. The lawyer who signed it, Nelson Mitten, is a Democratic committeeman in St. Louis County. His wife, Gina Mitten, sat in the House Democratic leadership — as Assistant Minority Floor Leader — in 2018, when the caucus deployed exactly these discretionary tools against Bob Burns. I draw no conclusion about anyone’s conduct from that, and none should be drawn: a lawyer is entitled to his clients, and a good argument is a good argument regardless of who makes it. I note it only because it draws the asymmetry inside a single household. The constitutional principle that the state may not punish people by unwritten, selectively applied standards is being argued, ably, by a family that has lived comfortably within an institution that disciplines its own by precisely that method. The doctrine is available downtown, for machines. It was never available to Bob Burns, and it was not available to Marlene Terry.

The petition asks the court to hold that you cannot criminalize by enforcement what the legislature never criminalized by statute. I agree. I’d only add the corollary it has no reason to reach: you cannot legitimately discipline by improvisation what no rule ever defined as misconduct. One of those propositions has a courthouse, an established doctrine, and a Supreme Court Justice’s prose behind it. The other has a stripped committee list and a vote you didn’t see coming.

A vague law, the petition says, quoting Justice Gorsuch, is no law at all. It’s right. I’d only add that a vague rule, applied by people with the power to apply it, is still very much a rule. It just isn’t one you can take to court.

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Sarah Unsicker served in the Missouri House of Representatives from 2017 to 2024, and as House Democratic Policy Chair from 2019-2022.

The technique is the timing.

In the spring of 2018, Missouri was in the middle of one of the more consequential political crises in recent state history. Governor Eric Greitens — Republican, former Navy SEAL, elected on an anti-establishment outsider platform — was unraveling on two separate legal tracks simultaneously.

On February 22, a St. Louis grand jury had indicted him on invasion of privacy charges: a woman with whom he’d had an affair in 2015 alleged he had photographed her partially nude, without consent, in the basement of his home, and used the image to coerce her silence. On March 1, the Missouri House had voted unanimously — bipartisan — to authorize a Special Investigative Committee to look into it.

That committee released its first report on April 11. It was devastating. The woman’s sworn testimony described being restrained, blindfolded, partially undressed, and photographed without consent. Nine days later, on April 17, Attorney General Josh Hawley announced a separate investigation: evidence that Greitens had taken the donor list from his veterans’ charity, The Mission Continues, and used it for political fundraising — a felony. Hawley publicly called on Greitens to resign.

By mid-April 2018, Missouri House Democrats were in a position they hadn’t occupied in years. A Republican governor was facing criminal exposure on two tracks. A bipartisan House investigation had produced damning public testimony. A Republican attorney general was calling for his own governor to go. The political ground was unusually clear.

Then, on April 20 — the same day St. Louis Circuit Attorney Kim Gardner charged Greitens with the charity donor list offense — recordings surfaced of Democratic State Representative Bob Burns calling into a radio show hosted by a man named Bob Romanik.

Bob Romanik ran AM stations in the St. Louis area for roughly a decade. His broadcasts were a reliable source of racist, misogynistic, and homophobic content. On February 9, 2018, he had used the N-word on air. This was not exceptional for his show; it was the pattern.

Burns, a Democrat representing a St. Louis County district, had called into Romanik’s KQQZ show multiple times in the weeks prior. The recordings, posted to a YouTube channel called “Romanik Watch” by then-State Senator Maria Chappelle-Nadal, captured Burns calling Romanik a truth-teller: “You preach truth, justice, and the American Way.” He told Romanik there was “a place in heaven for a guy like you.” He called him a friend. He praised his advocacy for veterans.

Burns had not used a slur. He had praised the man who did.

By April 21 — the day after the recordings surfaced — House Minority Leader Gail McCann Beatty had stripped Burns of his committee assignments, and a chorus of Democratic leaders including Senator Claire McCaskill and Auditor Nicole Galloway were calling for him to resign. By May, the full House Democratic Caucus had voted to expel him from its ranks. He refused to leave his seat.

The headline that spring, in the days when it mattered most, was not Republican governor faces impeachment but Democrats in disarray.

I was in the Missouri House when this happened. What I remember is how completely it worked — not in the sense that Burns faced any lasting accountability (he ran unopposed that November and won), but in the sense that the Democratic caucus spent its political energy on internal discipline at exactly the moment we needed it elsewhere. The tools available to the legislature for dealing with a member who has embarrassed the institution are, in practice, almost entirely social. And deploying those tools takes time, attention, and goodwill — all of which were in finite supply during a governor’s scandal that should have been a straightforward story about Republican misconduct.

I don’t know who ran the Romanik Watch YouTube channel. I don’t know how Chappelle-Nadal came to have the recordings, or whether she understood what releasing them at that moment would do to the caucus. These are questions worth asking, and I’m not in a position to answer them.

What I can say is that the effect was a textbook disruption operation: introduce a secondary crisis into the opposition at the moment the opposition has maximum leverage, force them to spend credibility on internal housekeeping, and muddy a clean narrative with complexity. Whether that effect was engineered or accidental is almost beside the point. The pattern is what matters.

This is how memetic warfare operates at the state level — and why it so rarely gets recognized as such. It doesn’t require fabricating anything. Burns really did make those calls. The recordings were real. No one put words in his mouth. What the operation required — if it was an operation — was only patience: the willingness to hold material until the moment its release would cause the most damage to the most people, none of whom were Bob Burns.

The target wasn’t Burns. The target was the House Democratic caucus’s ability to function as a coherent political force during the most significant accountability moment of the Greitens era.

Greitens resigned on June 1. By then, the Democrats had spent six weeks managing their own scandal instead of his. Greitens never faced impeachment. He was never exonerated, either. He left on his own terms, more or less, and the story of how Missouri’s House Democrats handled that moment is tangled enough that no one gets to claim it cleanly.

That’s what a good disruption operation does. It doesn’t have to win. It just has to make the other side lose the thread.

Sarah Unsicker served in the Missouri House of Representatives from 2017 to 2024.

I want to walk through one of the best-documented examples of memetic warfare, because the mechanics matter more than the politics. The pattern is the same regardless of the target, and anyone who writes about accountability needs the tools to recognize it.

The case: Maria Ressa

Maria Ressa is a Filipino-American journalist who co-founded Rappler, a digital newsroom in the Philippines that began reporting on the Duterte administration’s drug-war killings and the social-media infrastructure that protected them from political consequences. In 2021, she shared the Nobel Peace Prize with Russian journalist Dmitry Muratov “for their efforts to safeguard freedom of expression.”

What’s relevant to this analysis is what happened to her in between. After Rappler published its 2016 investigation into the network of paid trolls, sock-puppet accounts, and bot-amplified messaging that the Duterte campaign and government had been using, the same machinery turned on Ressa personally. Researchers at the International Center for Journalists (ICFJ), working with Rappler, later analyzed more than 450,000 social-media posts directed at her between 2016 and 2021. Their finding: roughly sixty percent of the abuse was not about her reporting at all. It was designed to damage her credibility — to make her radioactive as a source. In the month after Rappler’s exposé, she was averaging about ninety hate messages an hour.

Ressa and her team gave this tactic a name: “patriotic trolling” — state-sponsored online harassment dressed up as grassroots citizen outrage. The trolls were not random. Reporting and subsequent investigations have tied much of the coordination to a Philippine government communications office, with assists from political consultants whose names will be familiar to anyone who followed the 2016 U.S. election cycle.

The campaign worked, in the narrow sense the operators cared about. Ressa was charged with cyber-libel and tax evasion. Rappler’s operating license was challenged. She faced the real possibility of prison. Many of her sources stopped talking to her. Some of her former colleagues began repeating the trolls’ framing back to her in private, then in public. The Nobel committee, in effect, validated her reporting before her own country’s courts did.

What memetic warfare actually is

It is useful to separate three things people often blur together.

Disinformation is false content. Propaganda is persuasive content produced on behalf of a power. Memetic warfare is the delivery system — the use of viral cultural units (a phrase, an image, a recurring insult) to move a narrative through ordinary human social behavior faster than the truth can catch up. The genius, from the attacker’s perspective, is that the network does most of the work. The operators only have to seed the meme, amplify it during the critical early hours, and let identification do the rest. Each person who shares believes they are simply telling the truth as they see it. Many of them are.

This is why memetic warfare is so effective against accountability figures specifically. Accountability work depends on a baseline of credibility — the assumption that, if you say something happened, it is worth checking. Strip the credibility, and the work becomes invisible whether or not it is correct. The target does not have to be discredited; she only has to be made tiring.

The pattern, in plainer terms

Reading across Ressa’s case and the academic literature that has followed it, a few signals show up repeatedly. None of them, by themselves, prove coordination — but together they are a recognizable signature.

The volume comes from nowhere and arrives all at once. A target who has been writing about a politically sensitive subject for years suddenly experiences a surge of attacks across multiple platforms within hours of a specific piece. The accounts driving the surge are not, on inspection, organic readers; they include freshly created profiles, accounts with no posting history outside the campaign, and a small number of high-reach hubs that the smaller accounts amplify.

The framing is personal rather than substantive. The attacks rarely engage with the underlying claim. Instead they go after the target’s character, mental state, family, finances, or sexuality. This is the tell: a campaign concerned with truth would argue about facts. A campaign concerned with reach goes after the source.

The narrative is recyclable. The same phrase — “discredited,” “unhinged,” “paid by,” “everyone knows” — surfaces across accounts that do not appear to know each other. Two years later, a reporter who has never heard of the campaign will type the target’s name into a search bar and find the phrase staring back.

The institutional response lags. Platforms, prosecutors, and editors are slow to react because each individual post is, in isolation, defensible as opinion. The coordinated effect is illegible to systems that adjudicate one post at a time.

Why this matters for governance writing

The reason to know all of this is not to play counter-insurgency online. It is to read public information correctly.

If you are a citizen trying to evaluate a regulator, a legislator, a public integrity official, or a journalist, you will, at some point, encounter a confident assertion that the person is corrupt, crazy, or compromised. The assertion may be true. It may also be the visible output of a campaign whose operators are uninterested in whether it is true. The ability to tell the difference is now part of basic civic literacy.

A few practical habits help. Read the underlying work, not the commentary about the work. When you encounter a damning characterization, ask whether you can locate its origin — and whether the people repeating it appear to have. Treat a sudden, coordinated flood of identical phrasing as data about the campaign, not about the target. And give serious weight to formal accountability findings (Nobel committees, inspectors general, courts of appeal, peer-reviewed analyses) over volume on a platform — while recognizing that those institutions can themselves be slow and imperfect.

Ressa’s own warning, which she has repeated in venues from Harvard to her 2022 memoir How to Stand Up to a Dictator, is the part most worth carrying away: the techniques developed against her in Manila were not contained to Manila. They have been adapted, exported, and applied at every level of governance where someone with a record is in the way of someone with a platform. The defense, such as it is, runs through the reader.

Memetic warfare wins when we trust the meme more than the work. The work is harder. It is also still where the truth tends to be.

Sarah Unsicker is a former Missouri legislator who writes about policy and legislative craft from the concept to the courtroom.

Sources

• Nobel Peace Prize, Maria Ressa Facts: https://www.nobelprize.org/prizes/peace/2021/ressa/facts/

• ICFJ / Rappler big-data study of online violence against Maria Ressa (March 2021): https://www.icfj.org/our-work/maria-ressa-big-data-analysis

• “State-led and coordinated: ICFJ dives into online attacks vs Maria Ressa” (Rappler): https://www.rappler.com/world/global-affairs/icfj-case-study-online-violence-maria-ressa-march-2021/

• Columbia Journalism Review, “Targeted by Duterte”: https://www.cjr.org/60th/targeted-by-duterte-philippines-maria-ressa.php

• Harvard Gazette, Ressa on authoritarians and disinformation (2021): https://news.harvard.edu/gazette/story/2021/11/maria-ressa-warns-of-authoritarians-social-media-disinformation/

• Yale Law School, “Maria Ressa Ruminates on the Dangers of Disinformation”: https://law.yale.edu/yls-today/news/maria-ressa-ruminates-dangers-disinformation

• Maria Ressa, How to Stand Up to a Dictator (HarperCollins, 2022)

The Medicaid Director Demands States Tackle Fraud

News, as presented on TV, often ignores the decades of policy work behind the headlines. It may be difficult, even for astute consumers, to understand Fox News’ recent reporting, that “Dr. Oz puts all 50 governors on notice over billions lost to Medicaid fraud,” as anything other than a former Oprah TV star punishing every state for Minnesota’s Feeding our Future scandal, in which dozens of people laundered pandemic-era food relief funds. This reading couldn’t be further from the truth. The April 23 letters are the most recent action in a decades-long, bipartisan effort to address provider-side fraud—and they signal the federal government’s intent to move from planning to implementation.

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Dr. Mehmet Oz, a cardio-thoracic surgeon who was a professor at Columbia Medical School, leads the Centers for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS), which has one of the largest budgets in the entire federal government. He signed the letters personally.

Medicaid is second only to education in states’ line-item budget spending, and total Medicaid spending in 2023 reached over $900 billion. This alone makes Medicaid an attractive target for criminals, although the complexity of the system makes such fraud hard to pull off for your average bank robber. Two months ago, the Financial Crimes Enforcement Network of the U.S. Treasury (FinCEN) released an advisory to banks, warning of fraudsters, including transnational criminal organizations, laundering taxpayer money from welfare fraud.

Medicaid Fraud Explained

In 2005, the federal government identified “program integrity” within Medicaid as a priority for reducing the federal deficit. Included in the Deficit Reduction Act of 2005 was encouragement for states to recover false and fraudulent claims (Sec. 6031). It set up a Medicaid Integrity Program within CMS to review and audit Medicaid providers to reduce fraud, waste and abuse (Sec. 6034).

Discussion about Medicaid Fraud is often about participant fraud, not provider fraud. As a result, the concept of “fighting fraud in Medicaid” gets connected to the idea of people losing access to healthcare. The federal government is pushing states to shift their focus to providers who are billing for services not provided, which has been documented since at least 2005. The HHS Office of Inspector General (HHS-OIG) Criminal Enforcement Actions for 2005 looks remarkably similar to today’s docket. One physical therapist was ordered to pay nearly $1 million in restitution for billing services not performed, using unlicensed technicians without supervision, and paying referral kickbacks. A separate home health case involved billing for non-homebound and non-medically-necessary services. Two decades later, the categories of fraud are unchanged; the scale is not.

The Biden administration, in 2021, released a National Strategy on Countering Corruption. Every good strategy requires planning and implementation. The planning stage happened under the Biden administration. Implementation is happening under Trump.

The Letters Demand Planning and Implementation

On April 23, 2026 CMS sent letters to all 50 states and to state Medicaid directors, demanding they cut the flow of money to providers and nonprofits who profit from fraudulent billing practices. These letters were accompanied by a video on CMS’s Twitter/X Account that indicated that more enforcement is coming. These letters demand states immediately share their own planning phase related to Medicaid provider fraud, and they are consistent with the federal government’s implementation of the US Strategy on Countering Corruption. The letter to governors contains an implied threat, that “failure to do so will be considered as we evaluate the likelihood of fraud in each state moving forward.”

At the same time as the governors’ letters, a uniform letter was sent to state Medicaid directors, formally requesting, pursuant to CMS’ oversight responsibilities and state plan obligations, that each state submit a two-year provider revalidation strategy. Within 10 days of the letter, states must signal intent and the plans as they exist, or their intent to develop plans. Within 30 days, Medicaid directors are asked to provide a comprehensive strategy for re-evaluating high-risk Medicaid providers within two years. Once the revalidation is completed, CMS wants the results. That will allow them to cross-check between states.

Reading the Quiet Part

Medicaid recipients will appreciate that besides revalidation, the first paragraph of the letter also addresses provider directory validation. Patients’ frustration with a lack of accurate directory information is real, and it is a burden on both patients and the Medicaid system itself.

The letters specifically call out providers who do not have a National Provider Identification Number (NPI); and a provider’s lack of an NPI is a genuine red flag. However, some small businesses, especially HCBS providers (Home and Community Based Services, often a service provided for individuals with significant disabilities), may have let this slip through the cracks. Protecting good-faith providers who fail to perform administrative obligations is a natural tension in fraud-prevention effort in a system as complex as Medicaid.

In summary, CMS is moving in a consistent direction with regard to the age-old theme of “fighting corruption, fraud, waste, and abuse.” This carries forward anti-corruption priorities announced under the Biden Administration. The threat is real: states’ non-cooperation risks a targeted analysis by the federal government. The enforcement effort deserves support—and careful watching to ensure it lands on the criminal actors it’s meant to reach, not on the small honest providers who keep Medicaid running.

—Sarah Unsicker is a former Missouri legislator who writes about policy and legislative craft from the concept to the courtroom.

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