{"id":1125,"date":"2021-12-10T09:19:00","date_gmt":"2021-12-10T14:19:00","guid":{"rendered":"https:\/\/paragoninstitute.org\/index.php\/2021\/12\/10\/report-punishing-conservative-states\/"},"modified":"2024-04-19T16:09:02","modified_gmt":"2024-04-19T20:09:02","slug":"punishing-conservative-states","status":"publish","type":"post","link":"https:\/\/paragoninstitute.org\/medicaid\/punishing-conservative-states\/","title":{"rendered":"Punishing Conservative States: Payment Cuts to Hospitals Where Federal Spending is Already Low"},"content":{"rendered":"<section class=\"l-section wpb_row height_small color_primary with_img\"><div class=\"l-section-img\" role=\"img\" data-img-width=\"1920\" data-img-height=\"1080\" style=\"background-image: url(https:\/\/paragoninstitute.org\/wp-content\/uploads\/2021\/12\/iStock-1170241588_10.webp);background-position: bottom center;background-repeat: no-repeat;\"><\/div><div class=\"l-section-overlay\" style=\"background:rgba(15,19,31,0.35)\"><\/div><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-hwrapper valign_middle align_none\" style=\"--hwrapper-gap:0.3rem\"><div class=\"w-image us_custom_adc9e4e6 align_left\"><div class=\"w-image-h\"><img decoding=\"async\" width=\"1000\" height=\"1000\" src=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/12\/paragon-health-institute-icon-white.png\" class=\"attachment-large size-large\" alt=\"Paragon Health Institute Icon White\" loading=\"lazy\" srcset=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/12\/paragon-health-institute-icon-white.png 1000w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/12\/paragon-health-institute-icon-white-300x300.png 300w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/12\/paragon-health-institute-icon-white-150x150.png 150w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/12\/paragon-health-institute-icon-white-70x70.png 70w\" sizes=\"(max-width: 1000px) 100vw, 1000px\" \/><\/div><\/div><div class=\"w-vwrapper align_none valign_top\"><div class=\"wpb_text_column us_custom_8535c5f4\"><div class=\"wpb_wrapper\"><h2>Medicaid Reform Initiative<\/h2>\n<\/div><\/div><div class=\"wpb_text_column us_custom_5cd26a65\"><div class=\"wpb_wrapper\"><p>Reforming Government, Empowering Patients<\/p>\n<\/div><\/div><\/div><\/div><div class=\"w-separator size_huge\"><\/div><div class=\"w-separator size_large\"><\/div><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row height_small\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\" style=\"--additional-gap:10px;\"><div class=\"vc_col-sm-3 wpb_column vc_column_container\"><div class=\"vc_column-inner type_sticky\"><div class=\"wpb_wrapper\"><div class=\"g-cols wpb_row us_custom_30a16241 via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpb_text_column us_custom_e6f4972e has_text_color\"><div class=\"wpb_wrapper\"><p>Navigation<\/p>\n<\/div><\/div><nav Scroll_bar=\" \/* width *\/ ::-webkit-scrollbar {   width: 10px; }  \/* Track *\/ ::-webkit-scrollbar-track {   background: #f1f1f1; }  \/* Handle *\/ ::-webkit-scrollbar-thumb {   background: #888; }  \/* Handle on hover *\/ ::-webkit-scrollbar-thumb:hover {   background: #555; } \" class=\"w-menu us_custom_d0496a16 layout_ver style_links us_menu_1 with_children\" style=\"--main-gap:0.5rem;--main-ver-indent:0.8em;--main-hor-indent:0.8em;--main-color:inherit;--sub-gap:2px;\"><ul id=\"menu-punishing-conservative-states\" class=\"menu\"><li id=\"menu-item-4926\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4926\"><a href=\"#key-takeaways\">Key Takeaways<\/a><\/li><li id=\"menu-item-4927\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4927\"><a href=\"#building-back-better\">Build Back Better<\/a><\/li><li id=\"menu-item-4928\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4928\"><a href=\"#medicaid-reimbursements\">Medicaid Reimbursements<\/a><\/li><li id=\"menu-item-4929\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4929\"><a href=\"#dsh\">DSH<\/a><\/li><li id=\"menu-item-4930\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-4930\"><a href=\"#the-aca-and-dsh\">The ACA and DSH<\/a><ul class=\"sub-menu\"><li id=\"menu-item-4931\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4931\"><a href=\"#safety-net-funding\">Safety Net Funding<\/a><\/li><\/ul><\/li><li id=\"menu-item-4932\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-has-children menu-item-4932\"><a href=\"#a-perverse-result\">A Perverse Result<\/a><ul class=\"sub-menu\"><li id=\"menu-item-4933\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4933\"><a href=\"#the-evidence\">The Evidence<\/a><\/li><\/ul><\/li><li id=\"menu-item-4934\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4934\"><a href=\"#harm-to-those-in-need\">Harm to Those in Need<\/a><\/li><li id=\"menu-item-4935\" class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-4935\"><a href=\"#summary-and-recommendation\">Summary and Recommendation<\/a><\/li><\/ul><style>@media ( max-width:600px ){.us_menu_1 .menu{display:block!important}.us_menu_1 .menu>li{margin:0 0 var(--main-gap,0.5rem)!important}}<\/style><\/nav><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"vc_col-sm-9 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><h1 class=\"w-text us_custom_229b620a has_text_color\"><span class=\"w-text-h\"><span class=\"w-text-value\">Punishing Conservative States<\/span><\/span><\/h1><h3 class=\"w-text\"><span class=\"w-text-h\"><span class=\"w-text-value\">Payment Cuts to Hospitals Where Federal Spending is Already Low<\/span><\/span><\/h3><div class=\"w-separator size_small with_line width_default thick_1 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"w-hwrapper valign_top align_none\"><div class=\"w-image us_custom_41db1529 align_none\"><div class=\"w-image-h\"><img decoding=\"async\" width=\"1024\" height=\"266\" src=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/paragon-health-institute-logo-1024x266.webp\" class=\"attachment-large size-large\" alt=\"Paragon Health Institute\" loading=\"lazy\" srcset=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/paragon-health-institute-logo-1024x266.webp 1024w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/paragon-health-institute-logo-300x78.webp 300w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/paragon-health-institute-logo.webp 1800w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/div><\/div><\/div><div class=\"w-separator size_small with_line width_default thick_1 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"g-cols wpb_row via_flex valign_middle type_default stacking_default\"><div class=\"vc_col-sm-1\/5 wpb_column vc_column_container\"><div class=\"vc_column-inner us_custom_e633cb3f\"><div class=\"wpb_wrapper\"><div class=\"w-image us_custom_5fbd28cc style_shadow-1 align_center\"><div class=\"w-image-h\"><img decoding=\"async\" width=\"791\" height=\"1024\" src=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/Punishing-Conservative-States_coverart-01-791x1024.webp\" class=\"attachment-large size-large\" alt=\"Punishing Conservative States Coverart 01\" loading=\"lazy\" srcset=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/Punishing-Conservative-States_coverart-01-791x1024.webp 791w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/Punishing-Conservative-States_coverart-01-232x300.webp 232w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/Punishing-Conservative-States_coverart-01-scaled.webp 1978w\" sizes=\"(max-width: 791px) 100vw, 791px\" \/><\/div><\/div><div class=\"w-iconbox us_custom_b2452879 iconpos_left style_default color_primary align_left no_text\"><a href=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2021\/12\/Punishing-Conservative-States.pdf\" class=\"w-iconbox-link\" aria-label=\"Download\"><div class=\"w-iconbox-icon\" style=\"font-size:1rem;\"><i class=\"fal fa-download\"><\/i><\/div><\/a><div class=\"w-iconbox-meta\"><a href=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2021\/12\/Punishing-Conservative-States.pdf\" class=\"w-iconbox-link\" aria-label=\"Download\"><p class=\"w-iconbox-title\" style=\"font-size:0.8rem;\">Download<\/p><\/a><\/div><\/div><\/div><\/div><\/div><div class=\"vc_col-sm-4\/5 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpb_text_column us_custom_1f257949\"><div class=\"wpb_wrapper\"><h3>The Paper<\/h3>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>The paper critiques Medicaid DSH payment allocations, showing a bias against non-Medicaid expansion states, stressing the need for reform to fairly support hospitals serving low-income populations.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/div><div class=\"w-separator size_small\"><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"key-takeaways\"><div class=\"wpb_wrapper\"><h4>Key Takeaways<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><ul>\n<li>Through Medicaid\u2019s disproportionate share hospital (DSH) program, states are supposed to use federal funds to make payments to hospitals that provide uncompensated care to a high percentage of uninsured and low-income patients. The DSH program fails to equitably target public resources to safety net hospitals, ultimately failing low-income individuals and the uninsured.<\/li>\n<li>In 1992, Congress locked in a formula for calculating DSH funding to states which has\u2014for three decades\u2014rewarded states that had used gimmicky financing schemes to maximize DSH payments, thereby disadvantaging states that had not employed such schemes.<\/li>\n<li>States that expanded Medicaid under the Affordable Care Act have been much more likely to benefit from DSH\u2019s perverse funding structure. In 2021, Medicaid expansion states received 171 percent more federal DSH funding per uninsured person and 66 percent more federal DSH funding per low-income individual. Federal DSH funds cover 48 percent of the uncompensated care provided by hospitals in Medicaid expansion states compared to just 17 percent in non-expansion states.<\/li>\n<li>Irrationally, the Build Back Better Act would cut federal DSH funds only to non-Medicaid expansion states. These are typically states with already low DSH payments that also collectively saved the federal government hundreds of billions of dollars from 2014 to 2021 by not expanding Medicaid.<\/li>\n<li>Medicaid financing reform is necessary to equitably distribute federal aid to where it is most needed and to incentivize states to focus on providing value instead of maximizing the federal funds they can receive. Reforming DSH, as well as other Medicaid supplemental payment programs, to better target federal funds to safety net hospitals would be a good place to begin.<\/li>\n<\/ul>\n<\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"building-back-better\"><div class=\"wpb_wrapper\"><h4>Build Back Better: Cuts to Supplemental Medicaid Payments in Non-Medicaid Expansion States<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>The House-passed Build Back Better (BBB) Act cuts federal funding to hospitals in states that have not expanded Medicaid under the terms of the Affordable Care Act (ACA), but not in states that have expanded Medicaid.<span id=\"cmfSimpleFootnoteLink1-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink1\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Rachel Roubein, \u201cHow much to cut hospital payments is another Build Back Better battle,\u201d Washington Post, November 22, 2021,\" data-extlink=\"https:\/\/www.washingtonpost.com\/politics\/2021\/11\/22\/how-much-cut-hospital-payments-is-another-build-back-better-battle\/\" data-extlink_label=\"\">1<\/a><\/sup><\/span> The cuts would specifically result from a 12.5 percent reduction in Medicaid disproportionate share hospital (DSH) funding to non-expansion states.<span id=\"cmfSimpleFootnoteLink2-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink2\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cDisproportionate Share Hospital Payments,\u201d Medicaid and CHIP Payment and Access Commission (MACPAC), April 8, 2021,\" data-extlink=\"https:\/\/www.macpac.gov\/subtopic\/disproportionate-share-hospital-payments\/\" data-extlink_label=\"\">2<\/a><\/sup><\/span> DSH payments are the only type of Medicaid payment in statute that is explicitly intended to cover a portion of unpaid services hospitals provide to uninsured patients.<span id=\"cmfSimpleFootnoteLink3-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink3\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cMedicaid Base and Supplemental Payments to Hospitals,\u201d MACPAC, June 2021.\" data-extlink=\"https:\/\/www.macpac.gov\/wp-content\/uploads\/2020\/03\/MedicaidBase-and-Supplemental-Payments-to-Hospitals.pdf\" data-extlink_label=\"\">3<\/a><\/sup><\/span> DSH payments also serve to somewhat offset low Medicaid rates since base Medicaid payments often do not cover the hospitals\u2019 costs of providing services.<span id=\"cmfSimpleFootnoteLink4-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink4\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">4<\/a><\/sup><\/span><\/p>\n<p>DSH payments have never aligned well with the program\u2019s aims. Federal DSH funds are inequitable distributed across states, and Medicaid expansion states generally receive much larger federal DSH funding allotments than non-expansion states. The BBB Act\u2019s reduction of federal DSH funds to only non-expansion states would worsen this inequity.<\/p>\n<p>Most payments received by hospitals are direct payments for health care (fee-for-service payments) and payments from managed care plans to providers for services delivered (Medicaid managed care). States also make payments of federal funds to hospitals and other providers that are not direct payments for the services they provide. These \u201csupplemental\u201d payments include DSH payments, upper payment limit (UPL) payments, uncompensated care pool (UCP) payments, and delivery system reform incentive (DSRIP) payments.<span id=\"cmfSimpleFootnoteLink5-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink5\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid. In addition to DSH payments, which are thoroughly described in this paper, these federal supplemental payments include uncompensated\r\ncare pool (UCP) payments, upper payment limit (UPL) payments, and delivery system reform incentive payment (DSRIP) payments. UCP funds are\r\nintended to preserve fee-for-service (FFS) supplemental payments to hospitals after states have expanded the use of managed care; states receive\r\nthese funds through waivers approved by the Centers for Medicare and Medicaid Services. UPL payments are explicitly intended to supplement low\r\nFFS base payment rates by covering a portion of the difference between FFS base payments and the amount that Medicare would have paid for the\r\nsame service. DSRIP payments are Medicaid funds typically directed toward provider-led health care efforts, though states have also used DSRIP to\r\npreserve payments to hospitals to offset the growth in managed care.\" data-extlink=\"\" data-extlink_label=\"\">5<\/a><\/sup><\/span><\/p>\n<p>The BBB Act cuts not only DSH funding but also federal UCP assistance to non-Medicaid expansion states (but not to expansion states) by excluding payments from the UCP made on behalf of people who would be eligible for Medicaid if the state adopted the ACA\u2019s expansion. Eight states, including four non-Medicaid expansion states\u2014Florida, Kansas, Tennessee, and Texas\u2014receive UCP funding. The Congressional Budget Office projects the cuts to Medicaid\u2019s DSH and UCP programs would reduce federal spending by a total of $18.3 billion from 2023-2026 and $34.5 billion from 2023-2031.<span id=\"cmfSimpleFootnoteLink6-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink6\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cEstimated Budgetary Effects of Title III, Committee on Energy and Commerce, H.R. 5376, the Build Back Better Act,\u201d Congressional Budget Office, November 18, 2021,\" data-extlink=\"https:\/\/www.cbo.gov\/publication\/57623\" data-extlink_label=\"\">6<\/a><\/sup><\/span><\/p>\n<p>As the BBB Act moves to the Senate, hospitals are unsurprisingly pushing back on the legislation\u2019s DSH cuts.<span id=\"cmfSimpleFootnoteLink7-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink7\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Roubein, \u201cHow much to cut hospital payments is another Build Back Better battle.\u201d\" data-extlink=\"\" data-extlink_label=\"\">7<\/a><\/sup><\/span> Several senators have been vocal about their opposition to the cuts, including both Democratic senators from Georgia,<span id=\"cmfSimpleFootnoteLink8-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink8\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">8<\/a><\/sup><\/span> Raphael Warnock and Jon Ossoff, and all six Republican senators from Florida, Tennessee, and Texas.<span id=\"cmfSimpleFootnoteLink9-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink9\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cBlackburn Demands Answers on Biden Administration\u2019s Attack on State Medicaid Programs,\u201d U.S. Senator Marsha Blackburn of Tennessee, November 19, 2021,\" data-extlink=\"https:\/\/www.blackburn.senate.gov\/2021\/11\/blackburn-demands-answers-on-biden-administration-s-attack-on-statemedicaid-programs\" data-extlink_label=\"\">9<\/a><\/sup><\/span><\/p>\n<p>The House-passed legislation also contains large tax cuts for upper-income households in states with high state and local taxes, such as California and New York, through a provision which expands the amount of state and local taxes that can be deducted from income for federal tax purposes.<span id=\"cmfSimpleFootnoteLink10-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink10\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cDespite what its promoters say, raising the cap to $80,000 would provide almost no benefit for middle-income households. It would reduce their\r\n2021 taxes by an average of only $20. Even those making between $175,00 and $250,000 would get a tax cut of just over $400 or about 0.2 percent\r\nof after-tax income. By contrast, the higher SALT cap would boost after-tax incomes by 1.2 percent for those making between about $370,000 and\r\n$870,000 (the 95th to 99th percentile).\u201d Howard Gleckman, \u201cBuild Back Better 2.0 Still Raises Taxes for High Income Households and Reduces Them\r\nfor Others,\u201d Tax Policy Center at the Urban Institute &amp; Brookings Institution, November 11, 2021,\" data-extlink=\"https:\/\/www.taxpolicycenter.org\/taxvox\/build-backbetter-20-still-raises-taxes-high-income-households-and-reduces-them-others\" data-extlink_label=\"\">10<\/a><\/sup><\/span> The BBB Act\u2019s cuts to DSH and UCP funding for those in need combined with huge tax cuts for the wealthiest have led Republican senators, such as Marco Rubio of Florida, to frame the issue this way:<\/p>\n<p style=\"padding-left: 30px;\">The \u2026 bill is going to hurt Florida hospitals, especially those that treat low-income residents and the uninsured. It is reckless and irresponsible to cut the health care of some of our most vulnerable, including children, to pay for tax cuts for wealthy taxpayers in New York and California.<span id=\"cmfSimpleFootnoteLink11-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink11\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cBlackburn Demands Answers on Biden Administration\u2019s Attack on State Medicaid Programs\u201d\" data-extlink=\"\" data-extlink_label=\"\">11<\/a><\/sup><\/span><\/p>\n<p>In contrast, leading House Democrats suggest that the proposed DSH cuts make sense because other provisions of the BBB Act authorize subsidies for people in non-Medicaid expansion states with incomes below 100 percent of the poverty line. Under the BBB Act, these individuals\u2014who are currently ineligible for both Medicaid and premium subsidies\u2014would be entitled to enroll in an exchange plan with a zero out-of-pocket premium and minimal cost-sharing. Rep. Frank Pallone (D-New Jersey), chairman of the House Energy and Commerce Committee, laid out the rationale for the DSH cuts as follows:<\/p>\n<p style=\"padding-left: 30px;\">The people that are in those red states that were in that Medicaid gap, once they access the ACA and they have insurance, that\u2019s gonna more than make up for the hospitals and the caregivers in terms of whatever they\u2019re getting from the state for uncompensated care.<span id=\"cmfSimpleFootnoteLink12-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink12\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Roubein, \u201cHow much to cut hospital payments is another Build Back Better battle.\u201d\" data-extlink=\"\" data-extlink_label=\"\">12<\/a><\/sup><\/span><\/p>\n<p>This paper will show that Rep. Pallone\u2019s rationale for cutting funding to safety net hospitals just in Medicaid non-expansion states is problematic. States that have not adopted Medicaid expansion receive far less in federal assistance to finance health care services for the uninsured and low-income populations. The BBB Act would increase these inequities and harm safety net hospitals in poorer and more conservative states. Rather than the irrational approach in the BBB Act, policymakers should reform Medicaid financing and ensure that federal funds are more equitably distributed across states.<\/p>\n<\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"medicaid-reimbursements\"><div class=\"wpb_wrapper\"><h4>Medicaid Reimbursements: Huge Inequities Across States<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>The key feature of the joint federal-state Medicaid program is an open-ended federal reimbursement of state expenditures. States with lower per capita income have a higher percentage of their Medicaid expenditures reimbursed by the federal government than wealthier states do. Under the program\u2019s formula, the federal government reimburses half of state Medicaid expenditures in states with the highest per capita income and roughly three-quarters of expenditures by states with the lowest per capita income. The federal percentage, or share of a state\u2019s spending, is referred to as a state\u2019s federal medical assistance percentage (FMAP).<\/p>\n<p>Despite the higher reimbursement percentages for poorer states, wealthier states have developed much more expansive Medicaid programs, largely through broader eligibility categories and benefits. In reality, the federal government provides much more financial support for lower-income individuals\u2019 health care services in wealthy states than in poorer states. These inequities in federal funding have grown with the ACA\u2019s Medicaid expansion because the wealthy states and those with already profligate programs were more likely to expand.<\/p>\n<p>In 2018, federal Medicaid spending per person in poverty equaled $9,051.<span id=\"cmfSimpleFootnoteLink13-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink13\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Brian Blase, \u201cFunneling Coronavirus Relief to the States through Medicaid Will Aggravate Problems with the Program and Delay the Economic Recovery,\u201d Galen Institute, May 6, 2020,\" data-extlink=\"https:\/\/galen.org\/assets\/do-not-funnel-state-aid-through-medicaid-blase050620.pdf\" data-extlink_label=\"\">13<\/a><\/sup><\/span> The correlation between state per capita income and federal Medicaid spending per person in poverty provides a proxy for whether the federal Medicaid financing provides greater support to states with lower levels of fiscal capacity. If the federal government were providing greater Medicaid funding to poorer states, this correlation would be negative.<\/p>\n<p>However, wealthy states receive much greater federal Medicaid support per person in poverty than poorer states do. In fact, the correlation between federal spending per person in poverty and state per capita income (r=0.58) is high and positive.<span id=\"cmfSimpleFootnoteLink14-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink14\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Blase, \u201cFunneling Coronavirus Relief to the States through Medicaid Will Aggravate Problems with the Program and Delay the Economic Recovery.\u201d\" data-extlink=\"\" data-extlink_label=\"\">14<\/a><\/sup><\/span> Wealthy states\u2014such as New York, Massachusetts, Connecticut, New Hampshire, Vermont, Minnesota, and Maryland\u2014receive federal funding per person in poverty well above the national average, while states with lower per capita incomes tend to receive much lower support per person in poverty. In other words, the federal government\u2019s FMAP formula has incentivized the wealthy states to grow their Medicaid programs through broader eligibility, expanded benefits, and higher payment rates. Through these expansions, these states have successfully received much more funding from the federal government than poorer states have, despite the higher FMAP percentage for poorer states. Of note, excluding Medicaid expansion funding reduces the correlation between state per capita income and federal Medicaid spending per person in poverty, but only slightly to 0.54.<span id=\"cmfSimpleFootnoteLink15-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink15\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">15<\/a><\/sup><\/span> Thus, although Medicaid expansion worsened the disparity in federal Medicaid payments between wealthier and poorer states, that disparity largely pre-dates Medicaid expansion.<\/p>\n<\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"dsh\"><div class=\"wpb_wrapper\"><h4>DSH: Unfair to States and Hospitals<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>In addition to the basic funding formula, the federal government also provides states with DSH funding. DSH payments are intended to compensate hospitals that provide significant amounts of uncompensated, or poorly compensated, services. The DSH program has two essential features: 1) federal dollars are distributed to states, and 2) states make payments to hospitals.<\/p>\n<p>States began making Medicaid DSH payments to hospitals in 1981, but states were required to provide actual financing for their share of the payments, so DSH payments remained low.<span id=\"cmfSimpleFootnoteLink16-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink16\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cDisproportionate Share Hospital Payments.\u201d\" data-extlink=\"\" data-extlink_label=\"\">16<\/a><\/sup><\/span> The federal government then reimbursed each state at its FMAP rate for the payments it made to eligible hospitals.<\/p>\n<p>However, in the mid-1980s, the federal government issued a regulation and guidance that permitted states to fund their share of DSH payments with financing gimmicks, enabling the states to receive federal payments without having to actually pay their share. These gimmicks have been well-documented and effectively result in states obtaining federal Medicaid funds without having to make actual state contributions.<span id=\"cmfSimpleFootnoteLink17-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink17\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Brian Blase, \u201cMedicaid Provider Taxes: The Gimmick That Exposes Flaws with Medicaid\u2019s Financing,\u201d Mercatus Center, February 2016,\" data-extlink=\"https:\/\/www.mercatus.org\/system\/files\/Blase-Medicaid-Provider-Taxes-v2.pdf\" data-extlink_label=\"\">17<\/a><\/sup><\/span><\/p>\n<p>One such gimmick is a Medicaid provider tax. A state raises funds from a health care provider such as a hospital or nursing home, uses that tax revenue to make Medicaid payments to those providers, obtains federal funds through its Medicaid reimbursement, and then makes those providers whole through higher payments financed entirely by the federal funds.<\/p>\n<p>According to the Medicaid Access and Payment Commission (MACPAC), \u201cThis combination of unlimited DSH payments and financing flexibility was soon followed by a significant growth in DSH spending and, from 1990 to 1992, the total amount of DSH payments increased from $1.3 billion to $17.7 billion.\u201d<span id=\"cmfSimpleFootnoteLink18-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink18\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cDisproportionate Share Hospital Payments.\u201d\" data-extlink=\"\" data-extlink_label=\"\">18<\/a><\/sup><\/span> In 1992, Congress capped federal DSH funding to states due to concerns that federal DSH spending was surging unsustainably and \u201cthat some states were misusing DSH funds by making large DSH payments to hospitals operated by state or local government that were then transferred back to the state and used for other purposes.\u201d<span id=\"cmfSimpleFootnoteLink19-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink19\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cDisproportionate Share Hospital Payments.\u201d\" data-extlink=\"\" data-extlink_label=\"\">19<\/a><\/sup><\/span> This cap essentially locked states into the level of DSH they had in 1992, with only adjustments for inflation since 1992.<span id=\"cmfSimpleFootnoteLink20-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink20\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">20<\/a><\/sup><\/span> As a result, states that had employed the most gimmicky financing schemes to maximize DSH by 1992 have reaped a windfall over the past three decades compared to states that had not employed such schemes.<\/p>\n<p>States also have broad authority to determine the amount of DSH payments that hospitals receive. The DSH payments are supposed to be targeted to hospitals that provide greater amounts of uncompensated care, but in reality, political factors can influence states\u2019 allocations to hospitals. For example, according to an audit by the Government Accountability Office, \u201cstates generally provided more DSH payments to public hospitals (in comparison to private and non-profit hospitals) and teaching hospitals (as compared to non-teaching hospitals) relative to their share of total uncompensated care costs.\u201d<span id=\"cmfSimpleFootnoteLink21-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink21\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cMedicaid: States\u2019 Use and Distribution of Supplemental Payments to Hospitals,\u201d U.S. Government Accountability Office, July 29, 2019,\" data-extlink=\"https:\/\/www.gao.gov\/products\/gao-19-603\" data-extlink_label=\"\">21<\/a><\/sup><\/span> In practice, states can designate almost any hospital as eligible to receive DSH payments if the hospital has a Medicaid utilization rate of at least one percent.<\/p>\n<p>States\u2019 flexibility over DSH payments to hospitals combined with the huge variation in federal DSH allocations to states have led some states to make DSH payments to nearly all their hospitals while other states provide DSH payments to only a few hospitals.<span id=\"cmfSimpleFootnoteLink22-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink22\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">22<\/a><\/sup><\/span> Hospitals providing little uncompensated care in states with excessive federal DSH funding often still receive DSH payments because their states are spreading out the excessive funding, while hospitals providing much more uncompensated care in states with low federal DSH funding receive less support through the program.<\/p>\n<\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"the-aca-and-dsh\"><div class=\"wpb_wrapper\"><h4>The ACA and DSH: Attempted Cuts<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>The main provisions of the ACA significantly increased federal spending for health insurance through both exchange premium subsidies and Medicaid expansion. This new federal spending, which in 2020 totaled about $130 billion, reduced the number of people without coverage.<span id=\"cmfSimpleFootnoteLink23-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink23\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cFederal Subsidies for Health Insurance Coverage for People under 65: 2020 to 2030,\u201d Congressional Budget Office, September 29, 2020,\" data-extlink=\"https:\/\/www.cbo.gov\/publication\/56571\" data-extlink_label=\"\">23<\/a><\/sup><\/span> The ACA contained large cuts to DSH\u2014with reductions approaching 40 percent of federal DSH funding\u2014because its spending provisions were projected to significantly reduce hospital-provided uncompensated care, which it has in fact done. One study found that uncompensated care costs declined from 4.1 percent to 3.1 percent of operating costs in 2014, the year when the Medicaid expansion took effect.<span id=\"cmfSimpleFootnoteLink24-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink24\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"David Dranove, Craig Garthwaite, and Christopher Ody, \u201cUncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States: Health Affairs Journal.\u201d Health Affairs 35, no. 8 (2016), doi:\" data-extlink=\"https:\/\/doi.org\/10.1377\/hlthaff.2015.1344\" data-extlink_label=\"\">24<\/a><\/sup><\/span> A second study found similar results: uncompensated care costs declined by about 30 percent more in Medicaid expansion states than in non-expansion states in 2014.<span id=\"cmfSimpleFootnoteLink25-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink25\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Camilleri, Susan, \u201cThe ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care,\u201d Health Services Research, John Wiley\r\nand Sons Inc., May 8, 2017,\" data-extlink=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5980407\/\" data-extlink_label=\"\">25<\/a><\/sup><\/span><\/p>\n<p>Despite the decline in uncompensated care, the powerful hospital lobby pushed back on the DSH cuts included in the ACA, and the hospitals have convinced Congress to repeatedly delay them.<span id=\"cmfSimpleFootnoteLink26-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink26\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cDisproportionate Share Hospital Payments.\u201d\" data-extlink=\"\" data-extlink_label=\"\">26<\/a><\/sup><\/span> The cuts are supposed to begin again in fiscal year 2024\u2014at an amount of $8 billion per year.<\/p>\n<\/div><\/div><div class=\"w-separator size_small with_line width_default thick_2 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"wpb_text_column us_custom_7f2327a2\" id=\"safety-net-funding\"><div class=\"wpb_wrapper\"><h5>Safety Net Funding\u2014More Efficient in Non-Expansion States<\/h5>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>While federal Medicaid DSH payments are a small percentage of overall Medicaid funding, this program could be an efficient use of taxpayer resources by well-targeting those resources to hospitals where the need is greater. For example, the safety net financing approach may be much more efficient in non-expansion states than in expansion states. Non-expansion states can use federal funds\u2014through DSH payments as well as other supplemental payments\u2014to directly subsidize providers to treat uninsured people who have limited ability to finance their care as well as to make up for funding shortfalls from Medicaid.<\/p>\n<p>In contrast, in expansion states that increased Medicaid eligibility to working-age, nondisabled, and generally childless adults who typically do not consume much medical care, federal funds are used to reimburse states for high expansion-related expenditures to insurers. This financing approach also produces unintended consequences that include the replacement of private coverage with public coverage and the displacement of care as some people with more pressing health needs are crowded out by those with less pressing health needs.<span id=\"cmfSimpleFootnoteLink27-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink27\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Brian Blase and David Balat, \u201cIs Medicaid Expansion Worth It? A Review of the Evidence Suggests Targeted Programs Represent Better Policy,\u201d Texas Public Policy Foundation, April 21, 2020,\" data-extlink=\"https:\/\/www.texaspolicy.com\/is-medicaid-expansion-worth-it-a-review-of-the-evidence-suggeststargeted-programs-represent-better-policy\/\" data-extlink_label=\"\">27<\/a><\/sup><\/span><\/p>\n<p>Medicaid expansion has also caused a surge in improper payments in the program, which now approach $100 billion.<span id=\"cmfSimpleFootnoteLink28-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink28\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cHHS Agency Financial Report: Fiscal Year 2021,\u201d Department of Health and Human Services Office of Finance, November 29, 2021,\" data-extlink=\"https:\/\/www.hhs.gov\/about\/agencies\/asfr\/finance\/financial-policy-library\/agency-financial-reports\/index.html\" data-extlink_label=\"\">28<\/a><\/sup><\/span> These improper payments largely consist of government payments to insurers to administer managed care on behalf of enrollees who are not eligible for the program or who may not be eligible for the program (as their eligibility was not properly determined).<span id=\"cmfSimpleFootnoteLink29-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink29\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">29<\/a><\/sup><\/span><\/p>\n<\/div><\/div><div class=\"w-separator size_small with_line width_default thick_2 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"a-perverse-result\"><div class=\"wpb_wrapper\"><h4>A Perverse Result: Medicaid Expansion States Benefit Much More from DSH Than Non-Expansion States<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>Expansion states have benefitted from both the postponement of DSH payment cuts as well as the federal funds from expanding Medicaid. For the first three years of the expansion (2014-2016), the federal government paid states 100 percent of the costs of the expansion population. While that rate gradually declined starting in 2017, it is currently 90 percent and is scheduled to remain at 90 percent under current law.<span id=\"cmfSimpleFootnoteLink30-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink30\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"A provision of the BBB Act would increase the federal reimbursement rate for the ACA Medicaid expansion population to 93 percent from 2022-2025.\" data-extlink=\"\" data-extlink_label=\"\">30<\/a><\/sup><\/span><\/p>\n<p>Since many expansion states also benefit from their dodgy financing schemes that maximized their DSH payments in the early 1990s, the inequities in DSH payments across states now border on the absurd. Federal DSH funding per uninsured person averaged $432 in fiscal year 2021. Eight states plus the District of Columbia (D.C.) receive federal DSH payments of more than $1,000 per uninsured: D.C.\u2014$2,940; New Hampshire\u2014$2,216; Louisiana\u2014$1,965; New York\u2014$1,883; Rhode Island\u2014$1,775; Massachusetts\u2014$1,749; Maine\u2014$1,158; Connecticut\u2014$1,127; and New Jersey\u2014$1,088. All these states have adopted the ACA Medicaid expansion. On the other hand, five states receive federal DSH funding averaging less than $100 per uninsured person: Wyoming\u2014$4; Utah\u2014$75; Oklahoma\u2014$76; Tennessee\u2014$77, and Florida\u2014$84.<span id=\"cmfSimpleFootnoteLink31-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink31\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cAnnual Analysis of Disproportionate Share Hospital Allotments to States, Table 5A-7,\u201d MACPAC, March 2021,\" data-extlink=\"https:\/\/www.macpac.gov\/wp-content\/uploads\/2021\/03\/Chapter-5-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf\" data-extlink_label=\"\">31<\/a><\/sup><\/span> Overall, Medicaid expansion states receive an average of $674 in DSH funds per uninsured, more than two-and-a-half times the $249 in DSH funds per uninsured that non-expansion states receive.<span id=\"cmfSimpleFootnoteLink32-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink32\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"These averages were calculated after weighting states by their population.\" data-extlink=\"\" data-extlink_label=\"\">32<\/a><\/sup><\/span><\/p>\n<\/div><\/div><div class=\"w-image us_custom_37807850 align_none\"><a target=\"_blank\" href=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_1_PunishingConservativeStates-scaled.webp\" aria-label=\"XBB Table 1 PunishingConservativeStates\" class=\"w-image-h\"><img decoding=\"async\" width=\"1501\" height=\"2560\" src=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_1_PunishingConservativeStates-scaled.webp\" class=\"attachment-full size-full\" alt=\"XBB Table 1 PunishingConservativeStates\" loading=\"lazy\" srcset=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_1_PunishingConservativeStates-scaled.webp 1501w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_1_PunishingConservativeStates-176x300.webp 176w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_1_PunishingConservativeStates-600x1024.webp 600w\" sizes=\"(max-width: 1501px) 100vw, 1501px\" \/><\/a><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>Federal DSH funds are also inequitably distributed based on a state\u2019s low-income population (defined by a person who lives in a household with income below 200 percent of the federal poverty level). The national average of DSH funds per low-income individual is $155.<span id=\"cmfSimpleFootnoteLink33-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink33\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cAnnual Analysis of Disproportionate Share Hospital Allotments to States, Table 5A-7.\u201d\" data-extlink=\"\" data-extlink_label=\"\">33<\/a><\/sup><\/span> Eight states, as well as D.C., receive federal DSH payments that are more than twice the national average: New Hampshire\u2014$920; Louisiana\u2014$534; New Jersey\u2014$456; D.C. \u2014$445; Maine\u2014$412; New York\u2014$399; Connecticut\u2014$359; Missouri\u2014$347; and Rhode Island\u2014$342. All these states are Medicaid expansion states. Ten states receive DSH funding per low-income individual that is less than one-third of the national average: Wyoming\u2014$2; Tennessee\u2014$27; Utah\u2014$31; New Mexico\u2014$34; Oklahoma\u2014$35; Idaho\u2014$39; Florida\u2014$41; Hawaii\u2014$46; Montana\u2014$48; and Oregon\u2014$50. Overall, Medicaid expansion states receive an average of $182 in DSH funds per low-income individual, which is nearly 70 percent more than the average $110 in DSH funds per low-income individual that non-expansion states receive.<span id=\"cmfSimpleFootnoteLink34-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink34\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"These averages were calculated after weighting states by their population.\" data-extlink=\"\" data-extlink_label=\"\">34<\/a><\/sup><\/span><\/p>\n<p>Perhaps the best way to demonstrate the inequity of DSH funds is to contrast federal DSH funding as a percentage of uncompensated care provided by hospitals in each state. Overall, federal DSH funds covered an average of 48 percent of uncompensated care in Medicaid expansion states versus 17 percent of uncompensated care in non-expansion states.<span id=\"cmfSimpleFootnoteLink35-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink35\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"These averages were calculated after weighting states by their population.\" data-extlink=\"\" data-extlink_label=\"\">35<\/a><\/sup><\/span> In three states (Louisiana, New Hampshire, and Rhode Island) plus the District of Columbia, federal DSH funds actually exceed the amount of uncompensated care provided by hospitals.<span id=\"cmfSimpleFootnoteLink36-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink36\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cAnnual Analysis of Disproportionate Share Hospital Allotments to States, Table 5A-8,\u201d MACPAC, March 2021,\" data-extlink=\"https:\/\/www.macpac.gov\/wp-content\/uploads\/2021\/03\/Chapter-5-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf\" data-extlink_label=\"\">36<\/a><\/sup><\/span> In another five states (New Jersey, Pennsylvania, New York, Massachusetts, and Connecticut), federal DSH funds exceed 60 percent of uncompensated care. The top 13 states, including D.C., are all Medicaid expansion states. On the other side of the distribution, federal DSH payments cover less than 10 percent of uncompensated care in nine states (Wyoming, Hawaii, Tennessee, Oklahoma, Utah, Florida, Virginia, South Dakota, and Idaho), and another dozen states receive federal DSH payments that only cover between 10 percent and 20 percent of their uncompensated care costs.<\/p>\n<\/div><\/div><div class=\"w-image us_custom_37807850 align_none\"><a target=\"_blank\" href=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_2_PunishingConservativeStates-01.webp\" aria-label=\"XBB Table 2 PunishingConservativeStates 01\" class=\"w-image-h\"><img decoding=\"async\" width=\"2171\" height=\"584\" src=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_2_PunishingConservativeStates-01.webp\" class=\"attachment-full size-full\" alt=\"XBB Table 2 PunishingConservativeStates 01\" loading=\"lazy\" srcset=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_2_PunishingConservativeStates-01.webp 2171w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_2_PunishingConservativeStates-01-300x81.webp 300w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2024\/02\/XBB_Table_2_PunishingConservativeStates-01-1024x275.webp 1024w\" sizes=\"(max-width: 2171px) 100vw, 2171px\" \/><\/a><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>Table 2 summarizes the differences in DSH funding between Medicaid expansion and non-expansion states, showing the large disparities in funding. Of note, the correlations between the percentage of uncompensated care provided by state hospitals and federal DSH funding per uninsured (r=-0.31) and federal DSH funding per low-income individual (r=-0.16) are both negative. This means that less federal DSH funding is going to states with higher rates of uncompensated care, further evidence that the allocations across states are illogical.<\/p>\n<\/div><\/div><div class=\"w-separator size_small with_line width_default thick_2 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"wpb_text_column us_custom_7f2327a2\" id=\"the-evidence\"><div class=\"wpb_wrapper\"><h5>The Evidence: Non-Medicaid Expansion States Justified in that Decision<\/h5>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>The 12 states that have decided not to expand Medicaid, including Florida, Georgia, Tennessee, and Texas, have kept their programs focused on more vulnerable populations, such as low-income pregnant women, children, seniors, and people with disabilities. Their decisions have been justified. Wait times for appointments,<span id=\"cmfSimpleFootnoteLink37-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink37\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Sarah Miller and Laura Wherry, \u201cHealth and Access to Care during the First 2 Years of the ACA Medicaid Expansions,\u201d New England Journal of Medicine 376: 947-956,\" data-extlink=\"https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMsa1612890\" data-extlink_label=\"\">37<\/a><\/sup><\/span> ambulance response times,<span id=\"cmfSimpleFootnoteLink38-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink38\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Charles Courtemanche, et al, \u201cThe Affordable Care Act and Ambulance Response Times.\u201d Journal of Health Economics 67 (2019),\" data-extlink=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/31362143\/\" data-extlink_label=\"\">38<\/a><\/sup><\/span> and unnecessary visits to emergency rooms<span id=\"cmfSimpleFootnoteLink39-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink39\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Craig Garthwaite, et al, \u201cAll Medicaid Expansions Are Not Created Equal: The Geography and Targeting of the Affordable Care Act.\u201d National Bureau of Economic Research, October 14, 2019,\" data-extlink=\"https:\/\/www.nber.org\/papers\/w26289\" data-extlink_label=\"\">39<\/a><\/sup><\/span> have all significantly increased in Medicaid expansion states, indicating that resources have been redirected away from people who most need care. Medicaid expansion has not been associated with overall improvements in health outcomes.<span id=\"cmfSimpleFootnoteLink40-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink40\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Blase and Balat. \u201cIs Medicaid Expansion Worth It?\u201d\" data-extlink=\"\" data-extlink_label=\"\">40<\/a><\/sup><\/span> In fact, states that expanded Medicaid had worse mortality trends than states that did not expand Medicaid from 2014-2017, the first four years of the expansion.<span id=\"cmfSimpleFootnoteLink41-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink41\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Ibid.\" data-extlink=\"\" data-extlink_label=\"\">41<\/a><\/sup><\/span><\/p>\n<p>In addition to the disappointing health outcomes, the fiscal cost has been massive. Taxpayer spending exploded in expansion states, with enrollment busting past projections and improper payments soaring to unprecedented levels. The ACA\u2019s Medicaid expansion drove a quadrupling of federal improper payments in the program,<span id=\"cmfSimpleFootnoteLink42-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink42\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Brian Blase and Hayden Dublois, \u201cImproper Medicaid Payments Have Soared Since Obamacare,\u201d National Review, December 9, 2020,\" data-extlink=\"https:\/\/www.nationalreview.com\/2020\/12\/improper-medicaid-payments-have-soared-since-obamacare\/\" data-extlink_label=\"\">42<\/a><\/sup><\/span> which now equal about $100 billion annually.<span id=\"cmfSimpleFootnoteLink43-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink43\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"\u201cHHS Agency Financial Report: Fiscal Year 2021.\u201d\" data-extlink=\"\" data-extlink_label=\"\">43<\/a><\/sup><\/span> In addition, other problems with the expansion include the crowding out of other public priorities, the replacement of private coverage with public coverage, and increased financial dependency of state governments on a federal government with a monstrous national debt and expanding annual deficits.<span id=\"cmfSimpleFootnoteLink44-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink44\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Sam Adolphsen, Brian Blase, and Grace-Marie Turner, \u201cWhy States Should Not Expand Medicaid,\u201d The Foundation for Government Accountability, April 13, 2021,\" data-extlink=\"https:\/\/thefga.org\/additional-research\/why-states-should-not-expand-medicaid\/\" data-extlink_label=\"\">44<\/a><\/sup><\/span><\/p>\n<\/div><\/div><div class=\"w-separator size_small with_line width_default thick_2 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"harm-to-those-in-need\"><div class=\"wpb_wrapper\"><h4>Harm to Those in Need: Unfair Cuts to DSH in Non-Medicaid Expansion States<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>For 30 years, the DSH formula has harmed states that had not by 1992 utilized creative financing gimmicks to maximize federal payments. In general, the states that adopted the ACA\u2019s Medicaid expansion were also the ones that have unfairly benefitted from Washington\u2019s decision to lock state DSH funding allocations into place for the past three decades.<\/p>\n<p>Cutting DSH payments to non-expansion states while retaining them for expansion states\u2014as the BBB Act would do\u2014only increases this inequity, further harming those whom Medicaid was originally designed to assist. Cutting DSH just in non-expansion states seems particularly unfair because those states have saved the federal government hundreds of billion dollars over the past eight years by not expanding Medicaid, thereby not adding to the country\u2019s growing federal debt.<\/p>\n<p>Leading congressional Democrats point to the BBB Act\u2019s temporary premium subsidies, which are designed to assist people with income below the poverty line to obtain health coverage, as the rationale for the proposed DSH cuts in only non-Medicaid expansion states. It is also true that congressional Democrats are frustrated by the decisions of non-expansion states to turn down the ACA\u2019s terms.<span id=\"cmfSimpleFootnoteLink45-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink45\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\"Rachel Roubein and Susannah Luthi, \u201cDemocrats plot Medicaid expansion backdoor in red states refusing program,\u201d Politico, May 29, 2021,\" data-extlink=\"https:\/\/www.politico.com\/news\/2021\/05\/29\/medicaid-expansion-red-states-491353\" data-extlink_label=\"\">45<\/a><\/sup><\/span> In early 2021, congressional Democrats further enticed holdout states to expand by including enhanced payments in the American Rescue Plan Act for states that newly adopt the expansion. This attempt failed to convince any holdout states to expand. Cutting DSH and UCP funding only in non-expansion states is another attempt to coerce states into expanding their Medicaid programs. The carrots have not worked, so Congress is now using the stick.<\/p>\n<p>The purported rationale from congressional Democrats, which ignores the underlying inequities in DSH funding, falls apart for two additional reasons. First, the premium subsidy expansion would last only through 2025, but the DSH cuts would be permanent in non-expansion states. Second, if Congress wishes to cut DSH because other government subsidies have reduced uncompensated care, the DSH cuts should apply both in expansion states, where lower-income people are eligible for Medicaid per the ACA, and in non-expansion states, where lower-income people would be newly eligible for heavily subsidized exchange plans. In fact, many of the exchange plans are essentially Medicaid managed care plans.<\/p>\n<\/div><\/div><div class=\"wpb_text_column us_custom_16ce2194\" id=\"summary-and-recommendation\"><div class=\"wpb_wrapper\"><h4>Summary and Recommendation<\/h4>\n<\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>Federal financing of Medicaid needs significant reform. The main reason for needed reform\u2014federal Medicaid spending is approaching $500 billion annually<span id=\"cmfSimpleFootnoteLink46-0\" class=\"cmf_has_footnote_custom\"><sup><a href=\"#cmfSimpleFootnoteLink46\" class=\"et_smooth_scroll_disabled cmf_simple_footnote_link show-tooltip type1\" title =\" \u201cBaseline Projections,\u201d Congressional Budget Office, July 2021,\" data-extlink=\"https:\/\/www.cbo.gov\/system\/files\/2021-07\/51301-2021-07-medicaid.pdf\" data-extlink_label=\"\">46<\/a><\/sup><\/span> without generating sufficiently beneficial outcomes. Instead, the health of lower-income populations continues to deteriorate, medical resources are being misdirected, improper spending exceeds one-fifth of program expenditures, and exploding Medicaid growth is crowding out other vital public priorities. Fundamental and meaningful Medicaid financing reform would realign states\u2019 incentives, away from using Medicaid to maximize federal payments and instead toward obtaining the best outcomes and value for program recipients and taxpayers supporting the program.<\/p>\n<p>In the absence of large-scale reforms, there are many smaller, more targeted reforms that could further these aims. One such reform would be to DSH\u2014to disburse funds more equitably across states and to better target those funds to safety net providers within states. In fact, Congress could consider merging all of Medicaid\u2019s supplemental programs into one program with a more rational allocation across states.<\/p>\n<p>DSH reforms are needed because the federal government locked states into the same payment rates for the last three decades based on states\u2019 use of creative financing schemes at the time. This has resulted in large and unfair transfers across the states and the irrational allocation of federal support for safety net hospitals. As a result of the ACA\u2019s Medicaid expansion, the disparities in federal funding for uninsured and lower-income populations became more absurd. The result: Medicaid DSH transfers money from states such as Tennessee, Florida, Kansas, Georgia, and Texas (non-expansion states that did not employ gimmicky schemes to maximize federal DSH funds) to states such as New Hampshire, Louisiana, New York, Massachusetts, Connecticut, and New Jersey (expansion states that did employ gimmicky schemes to maximize DSH funds). These transfers have no policy rationale or justification. If policymakers want to sensibly reduce federal DSH payments, they should make the cuts primarily to expansion states.<\/p>\n<p>Federal DSH funding, and Medicaid supplemental payments in general, should be allocated amongst states based on the amount of uncompensated care provided by hospitals in those states. Since it is politically difficult to change funding allocations across states immediately, there could be a multi-year transition to move from the inequitable status quo to a fairer state allocation. Federal rules should also be tightened to ensure that states distribute the funds to the hospitals with the most need\u2014hospitals that treat the greatest number of uninsured and low-income patients\u2014instead of hospitals with the most political clout.<\/p>\n<\/div><\/div><div class=\"w-separator size_small\"><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h4>Footnotes<\/h4>\n<\/div><\/div><div class=\"wpb_text_column us_custom_5195ec9e\"><div class=\"wpb_wrapper\"><div class=\"pg-ft-sep\"><div class=\"sep-brdr\" style=\"width:25%; border-bottom:1px solid #000;\"><\/div><\/div><div id=\"cmfSimpleFootnoteDefinitionBox\"><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink1\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink1\">1<a href=\"#cmfSimpleFootnoteLink1-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Rachel Roubein, \u201cHow much to cut hospital payments is another Build Back Better battle,\u201d Washington Post, November 22, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.washingtonpost.com\/politics\/2021\/11\/22\/how-much-cut-hospital-payments-is-another-build-back-better-battle\/\"target=\"_blank\">https:\/\/www.washingtonpost.com\/politics\/2021\/11\/22\/how-much-cut-hospital-payments-is-another-build-back-better-battle\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink2\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink2\">2<a href=\"#cmfSimpleFootnoteLink2-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cDisproportionate Share Hospital Payments,\u201d Medicaid and CHIP Payment and Access Commission (MACPAC), April 8, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.macpac.gov\/subtopic\/disproportionate-share-hospital-payments\/\"target=\"_blank\">https:\/\/www.macpac.gov\/subtopic\/disproportionate-share-hospital-payments\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink3\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink3\">3<a href=\"#cmfSimpleFootnoteLink3-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cMedicaid Base and Supplemental Payments to Hospitals,\u201d MACPAC, June 2021.<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.macpac.gov\/wp-content\/uploads\/2020\/03\/MedicaidBase-and-Supplemental-Payments-to-Hospitals.pdf\"target=\"_blank\">https:\/\/www.macpac.gov\/wp-content\/uploads\/2020\/03\/MedicaidBase-and-Supplemental-Payments-to-Hospitals.pdf<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink4\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink4\">4<a href=\"#cmfSimpleFootnoteLink4-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink5\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink5\">5<a href=\"#cmfSimpleFootnoteLink5-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid. In addition to DSH payments, which are thoroughly described in this paper, these federal supplemental payments include uncompensated\r\ncare pool (UCP) payments, upper payment limit (UPL) payments, and delivery system reform incentive payment (DSRIP) payments. UCP funds are\r\nintended to preserve fee-for-service (FFS) supplemental payments to hospitals after states have expanded the use of managed care; states receive\r\nthese funds through waivers approved by the Centers for Medicare and Medicaid Services. UPL payments are explicitly intended to supplement low\r\nFFS base payment rates by covering a portion of the difference between FFS base payments and the amount that Medicare would have paid for the\r\nsame service. DSRIP payments are Medicaid funds typically directed toward provider-led health care efforts, though states have also used DSRIP to\r\npreserve payments to hospitals to offset the growth in managed care.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink6\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink6\">6<a href=\"#cmfSimpleFootnoteLink6-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cEstimated Budgetary Effects of Title III, Committee on Energy and Commerce, H.R. 5376, the Build Back Better Act,\u201d Congressional Budget Office, November 18, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.cbo.gov\/publication\/57623\"target=\"_blank\">https:\/\/www.cbo.gov\/publication\/57623<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink7\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink7\">7<a href=\"#cmfSimpleFootnoteLink7-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Roubein, \u201cHow much to cut hospital payments is another Build Back Better battle.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink8\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink8\">8<a href=\"#cmfSimpleFootnoteLink8-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink9\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink9\">9<a href=\"#cmfSimpleFootnoteLink9-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cBlackburn Demands Answers on Biden Administration\u2019s Attack on State Medicaid Programs,\u201d U.S. Senator Marsha Blackburn of Tennessee, November 19, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.blackburn.senate.gov\/2021\/11\/blackburn-demands-answers-on-biden-administration-s-attack-on-statemedicaid-programs\"target=\"_blank\">https:\/\/www.blackburn.senate.gov\/2021\/11\/blackburn-demands-answers-on-biden-administration-s-attack-on-statemedicaid-programs<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink10\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink10\">10<a href=\"#cmfSimpleFootnoteLink10-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cDespite what its promoters say, raising the cap to $80,000 would provide almost no benefit for middle-income households. It would reduce their\r\n2021 taxes by an average of only $20. Even those making between $175,00 and $250,000 would get a tax cut of just over $400 or about 0.2 percent\r\nof after-tax income. By contrast, the higher SALT cap would boost after-tax incomes by 1.2 percent for those making between about $370,000 and\r\n$870,000 (the 95th to 99th percentile).\u201d Howard Gleckman, \u201cBuild Back Better 2.0 Still Raises Taxes for High Income Households and Reduces Them\r\nfor Others,\u201d Tax Policy Center at the Urban Institute & Brookings Institution, November 11, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.taxpolicycenter.org\/taxvox\/build-backbetter-20-still-raises-taxes-high-income-households-and-reduces-them-others\"target=\"_blank\">https:\/\/www.taxpolicycenter.org\/taxvox\/build-backbetter-20-still-raises-taxes-high-income-households-and-reduces-them-others<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink11\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink11\">11<a href=\"#cmfSimpleFootnoteLink11-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cBlackburn Demands Answers on Biden Administration\u2019s Attack on State Medicaid Programs\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink12\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink12\">12<a href=\"#cmfSimpleFootnoteLink12-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Roubein, \u201cHow much to cut hospital payments is another Build Back Better battle.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink13\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink13\">13<a href=\"#cmfSimpleFootnoteLink13-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Brian Blase, \u201cFunneling Coronavirus Relief to the States through Medicaid Will Aggravate Problems with the Program and Delay the Economic Recovery,\u201d Galen Institute, May 6, 2020,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/galen.org\/assets\/do-not-funnel-state-aid-through-medicaid-blase050620.pdf\"target=\"_blank\">https:\/\/galen.org\/assets\/do-not-funnel-state-aid-through-medicaid-blase050620.pdf<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink14\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink14\">14<a href=\"#cmfSimpleFootnoteLink14-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Blase, \u201cFunneling Coronavirus Relief to the States through Medicaid Will Aggravate Problems with the Program and Delay the Economic Recovery.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink15\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink15\">15<a href=\"#cmfSimpleFootnoteLink15-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink16\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink16\">16<a href=\"#cmfSimpleFootnoteLink16-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cDisproportionate Share Hospital Payments.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink17\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink17\">17<a href=\"#cmfSimpleFootnoteLink17-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Brian Blase, \u201cMedicaid Provider Taxes: The Gimmick That Exposes Flaws with Medicaid\u2019s Financing,\u201d Mercatus Center, February 2016,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.mercatus.org\/system\/files\/Blase-Medicaid-Provider-Taxes-v2.pdf\"target=\"_blank\">https:\/\/www.mercatus.org\/system\/files\/Blase-Medicaid-Provider-Taxes-v2.pdf<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink18\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink18\">18<a href=\"#cmfSimpleFootnoteLink18-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cDisproportionate Share Hospital Payments.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink19\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink19\">19<a href=\"#cmfSimpleFootnoteLink19-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cDisproportionate Share Hospital Payments.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink20\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink20\">20<a href=\"#cmfSimpleFootnoteLink20-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink21\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink21\">21<a href=\"#cmfSimpleFootnoteLink21-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cMedicaid: States\u2019 Use and Distribution of Supplemental Payments to Hospitals,\u201d U.S. Government Accountability Office, July 29, 2019,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.gao.gov\/products\/gao-19-603\"target=\"_blank\">https:\/\/www.gao.gov\/products\/gao-19-603<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink22\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink22\">22<a href=\"#cmfSimpleFootnoteLink22-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink23\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink23\">23<a href=\"#cmfSimpleFootnoteLink23-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cFederal Subsidies for Health Insurance Coverage for People under 65: 2020 to 2030,\u201d Congressional Budget Office, September 29, 2020,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.cbo.gov\/publication\/56571\"target=\"_blank\">https:\/\/www.cbo.gov\/publication\/56571<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink24\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink24\">24<a href=\"#cmfSimpleFootnoteLink24-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">David Dranove, Craig Garthwaite, and Christopher Ody, \u201cUncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States: Health Affairs Journal.\u201d Health Affairs 35, no. 8 (2016), doi:<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/doi.org\/10.1377\/hlthaff.2015.1344\"target=\"_blank\">https:\/\/doi.org\/10.1377\/hlthaff.2015.1344<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink25\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink25\">25<a href=\"#cmfSimpleFootnoteLink25-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Camilleri, Susan, \u201cThe ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care,\u201d Health Services Research, John Wiley\r\nand Sons Inc., May 8, 2017,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5980407\/\"target=\"_blank\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5980407\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink26\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink26\">26<a href=\"#cmfSimpleFootnoteLink26-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cDisproportionate Share Hospital Payments.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink27\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink27\">27<a href=\"#cmfSimpleFootnoteLink27-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Brian Blase and David Balat, \u201cIs Medicaid Expansion Worth It? A Review of the Evidence Suggests Targeted Programs Represent Better Policy,\u201d Texas Public Policy Foundation, April 21, 2020,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.texaspolicy.com\/is-medicaid-expansion-worth-it-a-review-of-the-evidence-suggeststargeted-programs-represent-better-policy\/\"target=\"_blank\">https:\/\/www.texaspolicy.com\/is-medicaid-expansion-worth-it-a-review-of-the-evidence-suggeststargeted-programs-represent-better-policy\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink28\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink28\">28<a href=\"#cmfSimpleFootnoteLink28-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cHHS Agency Financial Report: Fiscal Year 2021,\u201d Department of Health and Human Services Office of Finance, November 29, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.hhs.gov\/about\/agencies\/asfr\/finance\/financial-policy-library\/agency-financial-reports\/index.html\"target=\"_blank\">https:\/\/www.hhs.gov\/about\/agencies\/asfr\/finance\/financial-policy-library\/agency-financial-reports\/index.html<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink29\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink29\">29<a href=\"#cmfSimpleFootnoteLink29-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink30\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink30\">30<a href=\"#cmfSimpleFootnoteLink30-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">A provision of the BBB Act would increase the federal reimbursement rate for the ACA Medicaid expansion population to 93 percent from 2022-2025.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink31\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink31\">31<a href=\"#cmfSimpleFootnoteLink31-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cAnnual Analysis of Disproportionate Share Hospital Allotments to States, Table 5A-7,\u201d MACPAC, March 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.macpac.gov\/wp-content\/uploads\/2021\/03\/Chapter-5-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf\"target=\"_blank\">https:\/\/www.macpac.gov\/wp-content\/uploads\/2021\/03\/Chapter-5-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink32\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink32\">32<a href=\"#cmfSimpleFootnoteLink32-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">These averages were calculated after weighting states by their population.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink33\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink33\">33<a href=\"#cmfSimpleFootnoteLink33-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cAnnual Analysis of Disproportionate Share Hospital Allotments to States, Table 5A-7.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink34\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink34\">34<a href=\"#cmfSimpleFootnoteLink34-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">These averages were calculated after weighting states by their population.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink35\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink35\">35<a href=\"#cmfSimpleFootnoteLink35-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">These averages were calculated after weighting states by their population.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink36\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink36\">36<a href=\"#cmfSimpleFootnoteLink36-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cAnnual Analysis of Disproportionate Share Hospital Allotments to States, Table 5A-8,\u201d MACPAC, March 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.macpac.gov\/wp-content\/uploads\/2021\/03\/Chapter-5-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf\"target=\"_blank\">https:\/\/www.macpac.gov\/wp-content\/uploads\/2021\/03\/Chapter-5-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink37\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink37\">37<a href=\"#cmfSimpleFootnoteLink37-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Sarah Miller and Laura Wherry, \u201cHealth and Access to Care during the First 2 Years of the ACA Medicaid Expansions,\u201d New England Journal of Medicine 376: 947-956,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMsa1612890\"target=\"_blank\">https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMsa1612890<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink38\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink38\">38<a href=\"#cmfSimpleFootnoteLink38-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Charles Courtemanche, et al, \u201cThe Affordable Care Act and Ambulance Response Times.\u201d Journal of Health Economics 67 (2019),<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/31362143\/\"target=\"_blank\">https:\/\/pubmed.ncbi.nlm.nih.gov\/31362143\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink39\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink39\">39<a href=\"#cmfSimpleFootnoteLink39-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Craig Garthwaite, et al, \u201cAll Medicaid Expansions Are Not Created Equal: The Geography and Targeting of the Affordable Care Act.\u201d National Bureau of Economic Research, October 14, 2019,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.nber.org\/papers\/w26289\"target=\"_blank\">https:\/\/www.nber.org\/papers\/w26289<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink40\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink40\">40<a href=\"#cmfSimpleFootnoteLink40-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Blase and Balat. \u201cIs Medicaid Expansion Worth It?\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink41\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink41\">41<a href=\"#cmfSimpleFootnoteLink41-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Ibid.<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink42\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink42\">42<a href=\"#cmfSimpleFootnoteLink42-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Brian Blase and Hayden Dublois, \u201cImproper Medicaid Payments Have Soared Since Obamacare,\u201d National Review, December 9, 2020,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.nationalreview.com\/2020\/12\/improper-medicaid-payments-have-soared-since-obamacare\/\"target=\"_blank\">https:\/\/www.nationalreview.com\/2020\/12\/improper-medicaid-payments-have-soared-since-obamacare\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink43\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink43\">43<a href=\"#cmfSimpleFootnoteLink43-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">\u201cHHS Agency Financial Report: Fiscal Year 2021.\u201d<\/span> <a class=\"cm_footnote_extlink\" href=\"\"target=\"_blank\"><\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink44\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink44\">44<a href=\"#cmfSimpleFootnoteLink44-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Sam Adolphsen, Brian Blase, and Grace-Marie Turner, \u201cWhy States Should Not Expand Medicaid,\u201d The Foundation for Government Accountability, April 13, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/thefga.org\/additional-research\/why-states-should-not-expand-medicaid\/\"target=\"_blank\">https:\/\/thefga.org\/additional-research\/why-states-should-not-expand-medicaid\/<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink45\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink45\">45<a href=\"#cmfSimpleFootnoteLink45-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\">Rachel Roubein and Susannah Luthi, \u201cDemocrats plot Medicaid expansion backdoor in red states refusing program,\u201d Politico, May 29, 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.politico.com\/news\/2021\/05\/29\/medicaid-expansion-red-states-491353\"target=\"_blank\">https:\/\/www.politico.com\/news\/2021\/05\/29\/medicaid-expansion-red-states-491353<\/a><\/div><div class=\"cmfSimpleFootnoteDefinitionItem cmfSimpleFootnoteLink46\"><span class=\"cmfSimpleFootnoteDefinitionItemId\" id=\"cmfSimpleFootnoteLink46\">46<a href=\"#cmfSimpleFootnoteLink46-0\" class=\"cm-footnote-backlink et_smooth_scroll_disabled\">\u2191<\/a> <\/span><span class=\"cmfSimpleFootnoteDefinitionItemContent\"> \u201cBaseline Projections,\u201d Congressional Budget Office, July 2021,<\/span> <a class=\"cm_footnote_extlink\" href=\"https:\/\/www.cbo.gov\/system\/files\/2021-07\/51301-2021-07-medicaid.pdf\"target=\"_blank\">https:\/\/www.cbo.gov\/system\/files\/2021-07\/51301-2021-07-medicaid.pdf<\/a><\/div><\/div>\n<\/div><\/div><div class=\"w-separator size_small\"><\/div><div class=\"g-cols wpb_row us_custom_deeef958 via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h4>Author<\/h4>\n<\/div><\/div><div class=\"w-grid filterable-grid type_grid layout_2374 cols_2 open_items_in_popup\" id=\"us_grid_1\" style=\"--gap:15px;\"><style>.layout_2374 .w-grid-item-h{}.layout_2374 .usg_hwrapper_1{transition-duration:0.3s;transform-origin:50% 50%;transform:scale(1) translate(0%,0%)}.layout_2374 .w-grid-item-h:hover .usg_hwrapper_1{transform:scale(1) translate(1%,0%);opacity:1}.layout_2374 .usg_post_image_1{width:30%!important;margin-right:5%!important;margin-left:0!important}.layout_2374 .usg_vwrapper_1{width:65%!important}.layout_2374 .usg_post_title_1{font-size:1.4rem!important}.layout_2374 .usg_post_content_1{font-size:14px!important;line-height:1.2!important}@media (max-width:600px){.layout_2374 .usg_post_image_1{width:100%!important;margin-right:0!important;margin-left:0!important;margin-bottom:5%!important}.layout_2374 .usg_vwrapper_1{width:100%!important}}<\/style><div class=\"w-grid-list\">\t<article class=\"w-grid-item size_1x1 post-1954 profile type-profile status-publish has-post-thumbnail hentry profile-type-leadership\" data-id=\"1954\">\r\n\t\t<div class=\"w-grid-item-h\">\r\n\t\t\t\t\t\t\t<a href=\"https:\/\/paragoninstitute.org\/profile\/brian-blase\/\" class=\"w-grid-item-anchor\" aria-label=\"Brian Blase, Ph.D.\"><\/a>\r\n\t\t\t\t\t\t<div class=\"w-hwrapper usg_hwrapper_1 align_none valign_top wrap\"><div class=\"w-post-elm post_image usg_post_image_1 as_circle has_width has_ratio\"><div style=\"padding-bottom:100%\"><\/div><a href=\"https:\/\/paragoninstitute.org\/profile\/brian-blase\/\" aria-label=\"Brian Blase, Ph.D.\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"1024\" src=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/brian-blase-1024x1024.webp\" class=\"attachment-large size-large wp-post-image\" alt=\"Brian Blase\" srcset=\"https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/brian-blase-1024x1024.webp 1024w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/brian-blase-300x300.webp 300w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/brian-blase-150x150.webp 150w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/brian-blase-70x70.webp 70w, https:\/\/paragoninstitute.org\/wp-content\/uploads\/2023\/11\/brian-blase.webp 1800w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><\/div><div class=\"w-vwrapper usg_vwrapper_1 align_none valign_top\"><h2 class=\"w-post-elm post_title usg_post_title_1 entry-title color_link_inherit\"><a href=\"https:\/\/paragoninstitute.org\/profile\/brian-blase\/\">Brian Blase, Ph.D.<\/a><\/h2><div class=\"w-post-elm post_content usg_post_content_1\">Brian Blase, Ph.D., is the President of Paragon Health Institute. Brian was Special Assistant to the President for Economic Policy&hellip;<\/div><\/div><\/div>\t\t<\/div>\r\n\t\t\t<\/article>\r\n<\/div><div class=\"w-grid-preloader\">\t<div class=\"g-preloader type_1\">\r\n\t\t<div><\/div>\r\n\t<\/div>\r\n\t<\/div>\t<div class=\"w-grid-json hidden\" onclick='return {&quot;action&quot;:&quot;us_ajax_grid&quot;,&quot;infinite_scroll&quot;:0,&quot;max_num_pages&quot;:1,&quot;pagination&quot;:&quot;none&quot;,&quot;template_vars&quot;:{&quot;columns&quot;:&quot;2&quot;,&quot;exclude_items&quot;:&quot;none&quot;,&quot;img_size&quot;:&quot;default&quot;,&quot;ignore_items_size&quot;:0,&quot;items_layout&quot;:&quot;2374&quot;,&quot;items_offset&quot;:&quot;1&quot;,&quot;load_animation&quot;:&quot;none&quot;,&quot;overriding_link&quot;:&quot;%7B%22type%22%3A%22popup_post%22%7D&quot;,&quot;post_id&quot;:0,&quot;query_args&quot;:{&quot;ignore_sticky_posts&quot;:1,&quot;post_type&quot;:&quot;any&quot;,&quot;post__in&quot;:[&quot;1954&quot;],&quot;posts_per_page&quot;:&quot;2&quot;},&quot;orderby_query_args&quot;:{&quot;orderby&quot;:{&quot;post__in&quot;:&quot;ASC&quot;},&quot;order&quot;:&quot;ASC&quot;},&quot;type&quot;:&quot;grid&quot;,&quot;us_grid_post_type&quot;:&quot;ids&quot;,&quot;us_grid_ajax_index&quot;:1,&quot;us_grid_filter_params&quot;:[],&quot;us_grid_index&quot;:1,&quot;page_args&quot;:[]}}'><\/div>\r\n\t<div class=\"l-popup\">\r\n\t<div class=\"l-popup-overlay\"><\/div>\r\n\t<div class=\"l-popup-wrap\">\r\n\t\t<div class=\"l-popup-box\">\r\n\t\t\t<div class=\"l-popup-box-content\">\r\n\t\t\t\t<div class=\"g-preloader type_1\">\r\n\t\t\t\t\t<div><\/div>\r\n\t\t\t\t<\/div>\r\n\t\t\t\t<iframe class=\"l-popup-box-content-frame\" allowfullscreen><\/iframe>\r\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t\t\t\t\t<div class=\"l-popup-arrow to_next hidden\" title=\"Next\"><\/div>\r\n\t\t\t<div class=\"l-popup-arrow to_prev hidden\" title=\"Previous\"><\/div>\r\n\t\t\t\t<div class=\"l-popup-closer\"><\/div>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><div class=\"wpb_text_column us_custom_0be19287\"><div class=\"wpb_wrapper\"><h4>Acknowledgements<\/h4>\n<\/div><\/div><div class=\"w-text\"><span class=\"w-text-h\"><span class=\"w-text-value\">The author thanks Doug Badger, who offered extremely helpful comments and feedback on this paper.<\/span><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/section>\n","protected":false},"excerpt":{"rendered":"Brian Blase, Ph.D., is the President of Paragon Health Institute. Brian was Special Assistant to the President for Economic Policy at the White House\u2019s\u00a0National Economic Council (NEC)\u00a0from 2017-2019, where he...","protected":false},"author":5,"featured_media":5172,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"footnotes":""},"categories":[757],"tags":[368,838],"external-media-outlet":[],"featured":[],"location":[],"publication-type":[723],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Punishing 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