With the federal government more than $23 trillion in debt, why should taxpayers continue to fund states’ accounting scams designed to bilk Washington out of additional Medicaid matching funds? It’s a good question, but one hospital lobbyists don’t want you to ask.

Late last year, the Trump administration released a proposed regulation designed to bring more transparency and accountability into the Medicaid program. The hospital sector in particular has begun an all-out blitz to try and overturn the rulemaking process. The need for the regulations demonstrates the problems with the current American health-care system, and how hospitals stand as one of the biggest obstacles to reform.

How the ‘Scam’ Works

The proposed regulations call for more transparency about supplemental payments within the Medicaid program. These payments, which take a variety of different forms, are considered supplemental in nature because they are not directly connected to the treatment of any one particular patient.

Many of these supplemental payments represent a way for states—and hospitals—to obtain a greater share of Medicaid matching dollars from the federal government. Hospitals, local governments, or other entities “contribute” funds to the state for the express purpose of obtaining additional Medicaid funds from Washington. Those matching funds then get funneled right back to many of the same entities that “contributed” the funds in the first place. As the old saying goes, it’s nice work if you can get it.

Over the years, even liberal groups have expressed concern about these shady funding mechanisms. In 2011, then-Vice President Joe Biden reportedly called provider taxes—in which hospitals and nursing homes pay an assessment, which gets laundered through state coffers to receive—a “scam.” Think about it: How often do you ask to pay higher taxes? Hospitals and nursing homes often propose new or higher provider taxes because they believe they will get their money back, and then some, via greater Medicaid payments.

Likewise, in 2000 the liberal Center for Budget and Policy Priorities decried the use of “Rube Goldberg-like accounting arrangements” that “use complex accounting gimmicks to secure additional federal funds for states without actual state matching contributions.” Yet two decades later, the scams continue to proliferate, because, as a 2005 government audit noted, most states have hired contingency-fee consultants for the sole purpose of bilking additional Medicaid matching funds from the federal government.

Hospitals’ Scare Tactics Rationalize Theft

The Trump administration’s proposal would make these accounting arrangements more transparent, with the goal of phasing out several of the most egregious arrangements altogether. This has prompted hospital executives to consider the proposed rule something just short of Armageddon.

During a 2008 debate on a similar set of Medicaid regulations put forward by the Bush administration, very few members of Congress even debated the regulations, as opposed to their effects on hospitals. Likewise, most hospital lobbyists and executives don’t try to defend the merits of these accounting scams. Instead, they just focus on the effects, with the typical “parade of horribles” examples: “If you end these payments, Tiny Tim will die.”

Hospitals’ reluctance to defend these opaque funding arrangements on their merits represents an implicit admission: They never should have received this money in the first place. Translation: “We stole that money fair and square—and you better let us keep stealing that money, or else” the hospital will close, people will lose their jobs, etc.

Hospitals’ Disingenuous Tactics

Some lobbyists on Capitol Hill claim they “only” want to delay the regulations, to allow for additional feedback and give hospitals time to adjust. It’s a ridiculous argument on multiple levels. First, as the policy paper from 2000 reveals, hospitals have engaged in these types of tactics for more than two decades, and they continue to grow and proliferate. The idea that hospitals need additional time to adjust to a problem they created seems laughable on its face.

Consider also what happened in 2008, when the Bush administration proposed a similar set of regulations designed to crack down on Medicaid financing abuses. Democrats passed a one-year moratorium preventing the administration from finalizing the rules, blocking them from taking effect.

Why only a one-year delay and not an outright ban? At the time, staff for the House Energy and Commerce Committee publicly stated that the moratorium “intended to delay the implementation of the Medicaid rules just long enough so that a future Administration can withdraw them.”

That’s exactly what ended up happening: The Obama administration withdrew the regulations upon taking office in 2009, so Congress didn’t have to pay for the cost associated with blocking them permanently. Hospital lobbyists asking for a delay of the regulations are hoping a Democrat wins the White House this fall, and can withdraw the regulations next year. They just won’t tell Republican staffers that their strategy is premised upon President Trump losing his re-election bid.

Let the Regulations Proceed, And Let States Decide

If the regulations went into effect today, they wouldn’t automatically lead to any hospitals closing down, or even hospitals losing any money. The Centers for Medicare and Medicaid Services (CMS) said it would work with states to transition away from the offending transactions over time.

That said, some governors oppose the regulations for the same reason hospitals do: It would force state governors and lawmakers to make difficult choices. If the loopholes that allow states to bilk more funds out of Washington end, then states would have to pony up “real” money from their coffers to maintain payments to providers, rather than funds obtained via accounting gimmicks. Hospitals would have to compete with other important state priorities—transportation, education, corrections, etc.—to maintain their existing payments.

But as the old saying goes, to govern is to choose. Better for a state to raise taxes—and be up-front and honest about doing so—to fund its Medicaid program than for that same state to use opaque gimmicks to squeeze out more federal dollars. The latter situation amounts to a (deferred) tax increase anyway, by adding more dollars to Washington’s ever-growing debt.

After decades of delays, and with our country’s debt growing ever-larger by the day, Medicaid deserves the fiscal integrity these new regulations would bring. They should go into full effect, and sooner rather than later.