Variation And Changes In The Targeting Of Medicaid Disproportionate Share Hospital Payments.

Little is known about how Medicaid disproportionate share hospital payments, which are intended to support hospitals that serve low-income patients, are allocated or whether allocation patterns have changed over time. We employed alternative definitions of targeting, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states. The most recent data indicate that 57.2 percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5 billion, in 2015. The majority of payments went to hospitals with Medicaid shares above the state-specific median (89.1 percent), hospitals with uncompensated care shares above the state-specific median (60.6 percent), or hospitals deemed as disproportionate share per statutory definitions (64.6 percent). However, among all hospitals receiving these payments, up to 31.6 percent of payments were allocated to hospitals that did not meet a given definition, and 3.2 percent went to hospitals that met none of them. These findings suggest that although the majority of the payments were targeted to hospitals serving low-income patients, opportunities exist to better align allocation with statutory goals and intent or to revise applicable statute.

US local public health department spending between 2008 and 2016 did not increase for communities in need.

BACKGROUND: Greater US local public health department (LPHD) spending has been associated with decreases in population-wide mortality. We examined the association between changes in LPHD spending between 2008 and 2016 and county-level sociodemographic indicators of public health need. METHODS: Multivariable linear regression was used to estimate the association between changes in county-level per-capita LPHD spending and 2008 sociodemographic indicators of interest: percent of population that was over 65 years old, Black, Hispanic, in poverty, unemployed, and uninsured. A second model assessed the relationship between changes in LPHD spending and sociodemographic shifts between 2008 and 2016. RESULTS: LPHD spending increases were associated with higher percentage points of 2008 adults over 65 years of age (+$0.53 per higher percentage point; 95% CI: +$0.01 to +$1.06) and unemployment (-$1.31; 95% CI: -$2.34 to -$0.27). Spending did not increase for communities with a higher proportion of people who identified as Black or Hispanic, or those with a greater proportion of people in poverty or uninsured, using either baseline or sociodemographic shifts between 2008 and 2016. CONCLUSION: Future LPHD funding decisions should consider increasing investments in counties serving disadvantaged communities to counteract the social, political, and structural barriers which have historically prevented these communities from achieving better health.