Hospital Uncompensated Care Pools: DISH by Another Name

CMS has returned to the thorny issue of non-Medicaid expansion state hospitals claiming (both contemporaneously and retroactively) DISH funds for uncompensated care provided. CMS maintains it has the authority to exclude uncompensated care pool days from the DSH calculation going forward, as noted by Modern Health Care. There is, after all, a CMS acknowledged access to DISH funds, short of Medicaid expansion, through the section 1115 waiver process.

It feels punitive, wail the hospitals in Texas, Florida, etc. who have mostly escaped the bite of DSH disqualification by presenting uncompensated care pool costs for DSH reimbursement. It was never designed to work like this, as DSH was designed to promote comprehensive care, nothing like what the services being pushed forward from the uncompensated care pools, notes CMS.

Indeed, the assumption of the drafters of the ACA appears to have been that the financials would drive Medicaid expansion and produce an organic evaporation of the need for huge uncompensated care pools. It may not be that, ten years out, twelve states would remain intransigent. Over ten years later, that has not happened, though the hospital associations of non-expansion states indicate that they wish it would.

The fascinating thing is that DSH is federal money, the thing that non-expansion states claim to repudiate. Now, we see a more nuanced argument: don’t tell us how to spend DSH funds. Or, acknowledging that DSH funds and uncompensated care pool funds are both supports designed to assist hospitals that seem large numbers of of uninsured patients, but insisting they are funds that may be used toward the same end.

There is a philosophical dispute lurking behind the argument over how to access DSH funds and how to spend them. Is it that needy people in on-expansion states may deserve DSH funded emergency care or urgent care but not comprehensive coordinated care?

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