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Among the myriad tactics Republicans are using to sabotage the Affordable Care Act, the "coverage gap" is perhaps the most visible. Because 26 GOP-led states have refused to accept the federally-funded expansion of Medicaid to their residents earning up to 138% of the poverty level, at least five million Americans will needlessly be left without health insurance in 2014. As it turns out, that Republican rejection will deal a second body blow to the red state health care systems that need help most by draining funds from hospitals that currently serve the uninsured.

As the New York Times reported, Memorial Hospital in Savannah, Georgia "is now facing the loss of nearly half of its roughly $100 million in annual subsidies known as disproportionate share hospital payments." The Times explained how the Republican temper tantrum after the Supreme Court made Medicaid expansion optional for the states is putting red state hospitals at risk:

Now, in a perverse twist, many of the poor people who rely on safety-net hospitals like Memorial will be doubly unlucky. A government subsidy, little known outside health policy circles but critical to the hospitals' survival, is being sharply reduced under the new health law.

The subsidy, which for years has helped defray the cost of uncompensated and undercompensated care, was cut substantially on the assumption that the hospitals would replace much of the lost income with payments for patients newly covered by Medicaid or private insurance. But now the hospitals in states like Georgia will get neither the new Medicaid patients nor most of the old subsidies, which many say are crucial to the mission of care for the poor.

As we'll see below, Savannah Memorial has plenty of company in Georgia.

Republican Governor Nathan Deal said no to $33 billion in new federal Medicaid funding over the next decade. But as the federal government significantly reduces funding on Disproportionate Share Hospital (DSH) payments for the care of the uninsured, states like Georgia which turned down Obamacare's Medicaid dollars will be on the hook to make up the difference. For Grady Memorial Hospital, the largest in the metro Atlanta area, what could have been an annual boon of $60 million and coverage for 27,000 uninsured patients instead will be a $45 million loss. Georgia taxpayers will have to pay more even as hospitals likely cut services. Meanwhile, three cash-strapped rural hospitals have already closed their doors. Another 15 may follow suit in 2014. All because a Republican Governor said "no" to free money from Washington, DC.

And the funding is virtually free to the states. The federal government will pay for 100 percent of the cost of the Medicaid expansion until 2017 and 90 percent after that. But the billions the "opt-out" states will have to come up with in future years will be more than offset by their extra costs to compensate hospitals and other providers for the care of the uninsured. As Ezra Klein and Evan Soltas summed up an analysis by the RAND Corporation of 14 Medicaid rejecting states:

It finds that the result will be they get $8.4 billion less in federal funding, have to spend an extra $1 billion in uncompensated care, and end up with about 3.6 million fewer insured residents.

So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That's a lot of self-inflicted pain to make a political point.

Which is just one of the reasons why an increasing number of red state governors are accepting the dollars from DC. GOP governors in Michigan, Pennsylvania and Ohio ran the numbers. In Ohio, Governor John Kasich's decision to take Washington's money will actually produce a $400 million surplus for the Buckeye State (one which Republican legislators want to give away in the form of more tax cuts). The simple math-and simpler consideration in insuring millions of indigent patients as the DSH funding is reduced over time is precisely why hospital associations in Texas, Kentucky, Georgia, Mississippi, North Carolina and every other state pleaded with Republican governors and legislatures to take Obamacare's money for Medicaid expansion. Just last week, the Fitch ratings agency released a special report titled, "Adverse Expansion: Hospitals, States and Medicaid," which warned that:
"Hospitals operating in states not expanding Medicaid, which usually have higher uninsured and poverty rates, will have to absorb the full impact of the ACA reimbursement cuts without the full benefit of increased insured volumes," said Adam Kates, Director in Fitch's Public Finance group. Texas, Florida, Georgia, Louisiana, Mississippi, and South Carolina are not expanding Medicaid and have among the highest uninsured and poverty rates, and some of the most stringent Medicaid eligibility requirements. Fitch believes hospitals in these states, particularly those with weak payer mixes, will be particularly vulnerable.
It's no wonder Arizona Governor Jan Brewer, certainly no friend of Barack Obama, explained her decision to extend Medicaid coverage to 300,000 more people in her state this way:
"It's pro-life, it's saving lives, it is creating jobs, it is saving hospitals."
Meanwhile in Georgia, Matthew Hicks, vice president for government relations at Grady lamented:
"The conversation we are having with the congressional delegation goes like this, 'If we don't expand Medicaid, what is the Georgia solution to indigent care?' So far they don't have an answer."
Sadly, the Republican answer to the low-income uninsured and the hospitals which care for them is pretty clear. Better dead and in the red than in bed with Obamacare.

Originally posted to Jon Perr on Sat Nov 09, 2013 at 01:11 PM PST.

Also republished by Kos Georgia and Daily Kos.

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Comment Preferences

  •  Classic cut off your nose (12+ / 0-)

    to spite the President because he's a blah ...

    "If you tell the truth, you'll eventually be found out." Mark Twain

    by Steven D on Sat Nov 09, 2013 at 01:37:35 PM PST

  •  Thanks, Jon, for reporting this. (7+ / 0-)

    This is precisely the situation here in Iowa as well, as our governor, Terry Branstad (R-Douchebag) has passed up federal funding in favor of a home-grown IowaCares plan, which costs more, covers fewer and less, and, last I knew, hadn't been given approval by the Feds as an acceptable plan. The likely eventuality is that a large number of Iowans will likely be unable to get coverage as their current plans expire, thanks to extended procrastination by our Republicans here, who were banking that the Obamacare rollout would be delayed or (their fondest hope) rescinded. Sadly typical.

    Your black cards can make you money, so you hide them when you're able; in the land of milk and honey, you must put them on the table - Steely Dan

    by OrdinaryIowan on Sat Nov 09, 2013 at 01:53:20 PM PST

  •  What is Georgia's solution to indigent care? (11+ / 0-)

    The answer was given at one of the debates among the candidates for the 2012 Republican nomination:  "Let 'em die!"

    "Ça c'est une chanson que j'aurais vraiment aimé ne pas avoir écrite." -- Barbara

    by FogCityJohn on Sat Nov 09, 2013 at 02:07:35 PM PST

  •  Thusfar their answer is "The Feds owe us the money (4+ / 0-)

    and we are being robbed." They are so used to disproportionate Federal payments that it has ripened into a true entitlement, no matter what state government does, in their minds. For a long time, the Federal money has blinded them to the damage otherwise done to them by the conservative state R governments they love, and now they are finding out what it is costing them. And the Rs aren't about to surrender anything to comply with paygo at the Federal level to do anything about it.

  •  I have said this before that the "medical" lobby (10+ / 0-)

    meaning Hospitals, Doctors, Nurses, and even Dentist are very soon going to start bringing the pain to Red state legistlators with some hard lobbying. No way are these wealthy groups going to stand by and not get compensated for their services. Especially once the bugs get worked out of the system, they aren't going to stand by and watch their colleagues in neighboring states get paid for things that they can't because of the GOP. That just isn't going to happen.

    I wouldn't be surprised if this starts to push these groups to the left. Just as many other professional and college educated voters have been trending left, this is the type of pollicy that will effect voting patterns.

    -1.63/ -1.49 "Speaking truth to power" (with snark of course)! Follow on Twitter @dopper0189

    by dopper0189 on Sat Nov 09, 2013 at 02:23:42 PM PST

    •  Already happened, and it's not just money. (10+ / 0-)

      I am on faculty at a major academic/ nonprofit medical center, and have been in medical world a long time. The shift has already happened, starting back in Reagan era and accelerated by the policies of George the Lesser. Cuts to hospital budgets and coverage of healthcare for the uninsured are part, but only a part. (Our hospital wound up stuck with over $100 million in costs at one point, and in litigation over it.)

      Most people in medical care and research also dislike things like cuts to NIH research budgets, slashing state and federal public health efforts, political appointees meddling with science in reports and educational policies, and wars. You want one example? Were it not for George II's blundering around in Afghanistan and Iraq, we'd very likely have finished eradicating polio, which was down to a few remote areas in - yep - Afghanistan, Pakistan, and Nigeria. Instead, we are now seeing cases in Syria. How long will it take to undo yet another side effect of wars? Not to mention, of course, the PTSD, brain damage, and other long-term sequelae among veterans, all preventable. No stupid wars = no war deaths and injuries.

      I don't know a single colleague who will admit to voting R, let alone supporting the crazy-pants version controlling that party.

  •  The framing of the pushback on this has (9+ / 0-)

    to be strong.  This is NOT the result of Obamacare.  This is the result of the Republican Governors/Legislatures refusing to expand Medicaid.  

    With the Decision Points Theater, the George W. Bush Presidential Library becomes the very first Presidential Library to feature a Fiction Section.

    by Its the Supreme Court Stupid on Sat Nov 09, 2013 at 04:17:15 PM PST

  •  See, our previous system HID the cost of care for (6+ / 0-)

    the poor with a roundabout payment to hospitals.

    Now, the red staters can't ask for those payments to be restored since it makes it obvious that a) we were paying through the nose for b) not very good care.  

    Nor will the red staters let hospitals close emergency rooms to non paying customers, because that would show people dropping dead on the street.

    Just take the freakin Medicaid expansion already.

    "One faction of one party in one House of Congress in one branch of government doesn't get to shut down the entire government just to refight the results of an election."

    by Inland on Mon Nov 11, 2013 at 06:34:15 PM PST

  •  Texas is the worst example. Close to criminal what (4+ / 0-)

    Perry and friends have done, and are doing, to Texas residents not in the 1 percent.

    •  The interesting thing about it... (0+ / 0-)

      ...is that the actions by Perry don't raise costs at the state level, but do so at the local level.

      Or, to put it another way, the cost of providing uncompensated care for people who could have gone onto Medicaid is going to come from the state, but from county hospital districts.

      Those hospital districts are in urban areas that are typically blue oasis in a sea of red.   The politics of it are pretty sickening, but the truth is that it won't hurt Perry and other statewide leaders very much at all.

      Political Compass: -6.75, -3.08

      by TexasTom on Mon Nov 11, 2013 at 08:34:16 PM PST

      [ Parent ]

  •  They don't care; they're evil nt (2+ / 0-)
    Recommended by:
    DonnaSC, Lilredhead

    nosotros no somos estúpidos

    by a2nite on Mon Nov 11, 2013 at 06:43:37 PM PST

    •  I live in Texas and.. (0+ / 0-)

      for the most part, you are correct.

      We, and I mean the state, keep putting these idiots in office. When this happens, the GOP/Texas Tea Party will spin it as Obamacare killed off hospitals. The worst part is the nimrods here will buy into it.

      ...the GOP seems perfectly willing to hold their breath until the whole country turns Blue.

      by tommy2tone on Mon Nov 11, 2013 at 07:29:54 PM PST

      [ Parent ]

  •  Is there ANY Chance (2+ / 0-)
    Recommended by:
    HadEnoughYet, Calamity Jean

    of getting this diary read by the Village Idiots in the
    New Hampshire Legislature ?

    Seriously.  The 400 Collective minds in the NH Legislature
    can't figure out what is going to happen to our Hospitals
    Next Year.

    Now all I need is a Bus load of 6th Graders to READ
    it to the members that don't know how.

    On Giving Advice: Smart People Don't Need It and Stupid People Don't Listen

    by Brian76239 on Mon Nov 11, 2013 at 06:45:46 PM PST

  •  BREAKING: GOP invents new way to stop voter fraud! (3+ / 0-)
    Recommended by:
    Lilredhead, a2nite, Calamity Jean

    just kill off the voters in red states by ruining healthcare system!

    it's a winner

    PLEASE donate to a global children's PEACE project: Chalk 4 Peace

    by RumsfeldResign on Mon Nov 11, 2013 at 07:03:36 PM PST

  •  turn on the lights!!! (0+ / 0-)

    watch the cockroaches scramble

    "We can't solve problems by using the same kind of thinking we used when we created them." - Albert Einstein

    by pickandshovel on Mon Nov 11, 2013 at 07:03:40 PM PST

  •  The Republicans are counting (2+ / 0-)
    Recommended by:
    Lilredhead, a2nite

    on the hospitals failing. They'll blame it on too much government involvement and call for completely unregulated, private hospitals. People without insurance won't even be allowed through the door, much less treated for urgent, life-threatening illnesses and injuries. They've run the same narrative too many times to count...

    "The subjects of every state ought to contribute towards the support of the government, as nearly as possible, in proportion to their respective abilities" - Adam Smith

    by Jesse Douglas on Mon Nov 11, 2013 at 07:10:29 PM PST

  •  Great article, but misses the strategy (2+ / 0-)
    Recommended by:
    tommy2tone, Notreadytobenice

    It is not self inflicted pain.  Citizens will pay for the obstruction not Republicans. Here's why.

    If these hospitals close or stop taking patients, do up think people will take the bank shot to blame Republicans for turning down Medicaid funding, or will ACA be blamed. Republicans know the answer, and play to win. Democrats put way too much faith in business being capable of moving a movement and way to little in Republicans cult like gravitation towards ending ACA and blocking the Presidents agenda.  They have been led to believe they are saving the country. Poor people losing out on health care is a price they are willing to pay.

    Dems that think providers are going to save them from the outcome of allowing blue dogs and Lieberman to water down their bill are sadly mistaken.  They are going to have to make hay with the bill they've got. The question is whether they can take a strong enough stance to hold off challengers.

    "Small Businesses Don't Build Levees" - Melissa Harris Perry

    by justmy2 on Mon Nov 11, 2013 at 07:23:06 PM PST

    •  It was SCOTUS that made the (3+ / 0-)

      Medicaid expansion optional, after pronouncing the ACA constitutional.  They were obviously aware that GOP governors and legislators would jump at this chance to take another poke at the black guy on the White House.  That it also would cause thousands of unnecessary deaths each year and needed hospitals going under was of no concern to these so-called justices in a totally politicized court.  Between this and the VRA debacle, the 5 GOP judges showed their contempt for the poor and near-poor, as well as people of color.  It's not the Dems fault.

      "It ain't right, Atticus," said Jem. "No, son, it ain't right." --Harper Lee, To Kill a Mockingbird

      by SottoVoce on Mon Nov 11, 2013 at 08:12:46 PM PST

      [ Parent ]

      •  Another SCOTUS shining moment... (0+ / 0-)

        "They were obviously aware that GOP governors and legislators would jump at this chance to take another poke at the black guy on the White House."

        Not so sure about that SV. Don't think SCOTUS considered.
        Hope it bites Roberts in the ass.

        This is a big deal.
        Puggy's to sneak a transfer of ACA funds to old program?

        A lot of Dem's will support same for progressive reasons.
        Including President Obama?

        Hope POTUS hangs tough and tells these bastards it's "my way or the highway."

        ACA is his legacy and why t'is called Obamacare.

        Good comment SV

    •  Compromise is still in the air... (0+ / 0-)

      T'is all in the arms of POTUS as to whether or not he will let ACA go down the shit-tubes with more compromise.

      Look for refunding of the old program with a lot of Dem support for "progressive" reasons.

      Hope President Obama "just says no."

  •  Who cut what? (0+ / 0-)

    Please correct me if I'm wrong, but my understanding is that the cut to the disproportionate care subsidy was built into the ACA by the Democrats in order to help fudge those budgetary target numbers for CBO scoring. Meantime, even in states that are expanding Medicaid, funding cuts for this have already begun.  What it would take to fix this is amendment to the ACA. Is that not correct?

    •  Simple It would take GOP assholes to stop (2+ / 0-)
      Recommended by:
      Nance, Notreadytobenice

      trying to kill the ACA.

      In particular in states where GOP governors or state legislatures refused Medicaid expansion.

      This is your world These are your people You can live for yourself today Or help build tomorrow for everyone -8.75, -8.00

      by DisNoir36 on Tue Nov 12, 2013 at 03:40:45 AM PST

      [ Parent ]

      •  Move to strike as nonresponsive. n/t (0+ / 0-)
        •  Move to strike as bullshit (1+ / 0-)
          Recommended by:
          Calamity Jean
          The subsidy, which for years has helped defray the cost of uncompensated and undercompensated care, was cut substantially on the assumption that the hospitals would replace much of the lost income with payments for patients newly covered by Medicaid or private insurance.
          The subsidy was to pay for people who went to hospitals and didn't have insurance to help pay the costs.  If people are covered under ACA or Medicaid then the number of people going to the hospitals without insurance to help pay most or all of the costs goes down significantly.  That being the case, the subsidy to help defray lost payments from people who cannot pay is no longer needed.

          So the reality is that republican assholes who thought they were being slick by opting out of the Medicaid expansion didn't read the fine print and fucked themselves and their constituents over.  Medicaid expansion would cover the care of most of those people who would fall into the group of hospital patients unable to pay for their care and would have resulted in those hospitals not needing that subsidy.  

          So thanks for your concern but those cuts were NOT put 'in order to help fudge those budgetary target numbers for CBO scoring.' It was a logical cost savings step.  The only problem is the Democrats were dealing with republican assholes who are anything but logical.  

          So in the end my answer is as correct as any other.  All it takes is for GOP assholes to stop trying to fucking kill the ACA for political purposes and expand Medicaid.  Then those subsidies won't be needed and those hospitals won't be losing money.  

          This is your world These are your people You can live for yourself today Or help build tomorrow for everyone -8.75, -8.00

          by DisNoir36 on Tue Nov 12, 2013 at 06:06:27 AM PST

          [ Parent ]

          •  CBOs version (0+ / 0-)
            states and local governments will probably realize savings in existing programs that provide direct care to people who are uninsured or that cover uncompensated costs incurred by providers serving uninsured residents. Pressure to expand Medicaid coverage is also likely to come from health care providers that stand to gain when more people have coverage. In particular, hospitals that will receive smaller disproportionate share payments from Medicaid under the ACA may exert pressure on states to make up for those losses by expanding Medicaid eligibility.17
            At the same time, there are significant disincentives for states to expand Medicaid eligibility. One is that states would ultimately have to bear some costs for an expansion of Medicaid coverage during a period when their budgets are already under pressure, in part from the rising costs of the existing Medicaid program. Health care costs tend to rise faster than those for other services or products in the economy. And although the 10 percent share of the costs of newly eligible people that states would ultimately bear would be a small share of total additional Medicaid spending, it would nevertheless represent a large extra cost for some states.
            http://www.google.com/...

            So, probably not merely Republicans looking to kill ACA, but multiple interests. And in the end, if you argue that this is due to the SC rejection of the requirement on the states, it stands as a further instance of incompetent legislating, as it was perfectly predictable that this requirement was highly subject to challenge.

      •  Watch for an attempt to re-fund the old program... (0+ / 0-)

        and with a lot of Dem support for progressive reasons.

        This is all about money. In an alternate universe:

        POTUS to puggy's "Pound sand on refunding old program."

  •  Let's Hope (2+ / 0-)
    Recommended by:
    HadEnoughYet, lynneinfla

    That Wendy Davis can win in Texas, and begin taking this state back from the regressive a$$hole rethugs. who think only of themselves, and could care less about the poor in this state.  I am happy to report that I have gotten many thumbs up for my Texas Democrat bumper sticker.  I had a woman approach me in the parking lot of a grocery store and tell me she is a Democrat too, but is afraid to put a bumper sticker on her car due to the horrible way rethugs, respond when they find out a person is a Democrat here in Texas.  I smiled and told her I was glad she spoke to me because I am finding out there are many more Democrats in Texas than people think.  I am not one of those quiet Democrats who does not defend herself when one of the rethugs start any crap with me.  I simply state facts to them about their ignorance of rethug policies and they usually stop with their rudeness and BS.  It is time for all of the Democrats and Progressive minded people to hit back at the rethugs, and let them know we are fed up with the racist bigoted way they operate.

    Democrat Without Suffix, Prefix, Apology or Explanation .

    by Lilredhead on Mon Nov 11, 2013 at 07:53:12 PM PST

  •  Poverty Rate (2+ / 0-)
    Recommended by:
    Notreadytobenice, Calamity Jean

    I suppose that's one way of reducing the rate of poverty--kill the poor people

  •  What about undocumented people? (2+ / 0-)
    Recommended by:
    HadEnoughYet, Notreadytobenice

    I'm worried about the hospitals in communities with large numbers of undocumented people, who are excluded from Medicaid, the ACA, and every other way of getting health insurance. They are going to continue to show up in ERs, without any ability to pay the bill. In other words, the Medicaid-expansion gap is only one of several gaps in coverage, and the one based on immigration status is overt -- planned, on policy grounds -- and probably affects at least as many people.

    With the reductions in funding to hospitals and community clinics, how does the Administration think the undocumented people will get served? (I realize that the GOP answer is: Let them go back to where they came from, or die. But presumably the Administration has some other options in mind.)

    •  You make it sound like it's President's fault... (0+ / 0-)

      Put the blame where it belongs. There's a lot of support by Dems, for progressives reasons, to re-fund the old program because of puggy's resistance to ACA.

      Hope President Obama says not in the cards.

    •  The disproportionate care subsidy was only (1+ / 0-)
      Recommended by:
      JeffW

      reduced, not eliminated.  Hospitals will continue to get help with the cost of undocumented people showing up in emergency rooms.  

      "My country, right or wrong; if right, to be kept right; and if wrong, to be set right." -- Sen Carl Schurz 1872

      by Calamity Jean on Tue Nov 12, 2013 at 07:03:44 PM PST

      [ Parent ]

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