Medicaid revenues may determine whether public hospitals will survive. Public hospitals participate aggressively in the public market competition for their states' Medicaid dollars. States must decide whether the survival of public hospitals, as providers of last resort to both Medicaid and uninsured patients, is of continuing importance to their Medicaid programs. Cities, if the states were willing, alternatively could voucher uninsured patients and direct Medicaid patients to the private hospitals that would outlive closed public hospitals. In fact, Medicaid's managed care programs already have heightened this competition, by organizing sufficiently large populations of prepaid Medicaid patients to attract networks of private providers to offer discounted prices, in competition with public hospitals for this market.

Although Medicaid has been a comparatively poor payer, nationally, almost half of public hospitals7 funding comes from this source of revenue. Urban public hospitals can barely live with Medicaid revenues, but the extent to which they can live without Medicaid revenues is being determined by surprising new turns in market competition for the revenue. A period of expansive and expensive new congressional mandates for the joint federal-state program was followed in the early 1990s by the introduction by the states of Medicaid revenue maximization strategies. The states' funding levels, the bases for matching federal contributions, were artificially elevated by provider taxes, provider donations, and intergovernmental transfers. The revenue from all these sources was returned to these providers through the Disproportionate Share Hospital subsidy program for Medicaid-dependent hospitals, as soon as the federal revenue match was calculated, based upon the inflated figures. These practices currently are being stymied, and states simultaneously have escalated competitive bidding by private market managed care providers for Medicaid patients. Missouri has been in the forefront of states moving to maximize the federal Medicaid revenue match and to return Disproportionate Share Hospital funds to providers. St. Louis's public hospital, Regional Medical Center, has been weaned off its local government subsidies, as the intergovernmental transfer and DSH enticements compromised the stability of that hospital's revenue picture. Now, unprotected by an integrated healthcare system or other major role in a regional hospital network, this urban public hospital must struggle to survive within its Medicaid managed care competitive market. The question for the state of Missouri is whether perpetuating a future for Regional will ensure its Medicaid patients a traditional caring public medicine alternative as a fallback position, if Medicaid's present foray into the private market goes awry. For Regional and the city of St. Louis, the question is whether they can any longer count upon traditional state Medicaid revenue and financial support.

Volume 22

Numbers 11-12