Why Red State Govs May Embrace Medicaid Expansion

Keckley thinks that DSH payments may not disappear quite as quickly as was originally forecasted, "but there will be offsetting that much more pressure through the back door."

"The front door is reimbursement and the feds will probably get a few of those dollars back,  especially for safety net hospitals in light of the fact that not as many people are going to be insured through Medicaid," he says.

"But on the back end I suspect CMS will be more aggressive on fraud and necessary care and accelerate these pilots so they can get the money back in terms of penalties or that they simply don't have to payout as much because of under performers."

"The mood at CMS is that fraud is under-captured and they haven't figured out how to deal with it," he says. "They aren't going to do pay and chase anymore and they think this necessary care issue is big. That there is so much being done that the evidence says is unnecessary that they will have reason to go to the providers and the plans that have allowed it and say 'we need a give back. You can't get away with this anymore."