The tensions between hospitals and the Trump administration have persisted for years.

The hospital industry went to war with the White House in 2017 over Trump’s efforts to repeal the Affordable Care Act, saying that rolling back the sweeping health law would harm patients and do damage to their bottom lines. They’ve continued that fight as Trump has tried to strike down the law in court, with American Hospital Association CEO Rick Pollack calling the position “misguided.”

Hospitals also have fought over numerous Medicaid changes spearheaded by Verma, including a new “fiscal accountability” proposal that would tighten hospitals’ ability to collect Medicaid funding. Hospitals currently use a variety of financial arrangements to pump up their Medicaid revenue, such as supporting state taxes that allow them to draw down even more money in federal matching funds. Verma has called the arrangements industry-friendly gimmicks and wants to do away with them.

“Hospitals were already concerned about the rule — and moreso with coronavirus staring them in the face,” said Joel McElvain, a partner in King & Spalding’s health care group who’s represented hospitals in lawsuits against the administration. McElvain warned that states would need to come up with new financial arrangements to support hospitals if the rule, a top priority for Verma, is finalized during the coronavirus outbreak.

“It’s a time when rural hospitals are already struggling and facing real difficulty if worst-case scenarios come true in the coming weeks,” McElvain said.

Meanwhile, hospitals have spent years fighting back against a slew of Trump administration funding cuts to Medicare, Medicaid and public health initiatives. Among Trump’s most recent proposals: an $18 million cut to the federal health department’s own hospital preparedness program, announced just last month, on the eve of the coronavirus outbreak.

“The hospital preparedness program exists so hospitals prepare for this exact thing,” said a former HHS official. “The whole point is to prepare them so they can respond to all hazards - from hurricanes to pandemics to biological attacks.”

While Trump’s battles with the pharmaceutical industry have gotten considerable headlines, some of his aides have believed that hospitals were a larger problem, citing the costs that ever-larger systems have passed along to patients and pointing to policies that they say gamed the system. They also haven’t agreed with hospitals’ warnings that their bottom lines have suffered under this administration.

“The argument is so ridiculous,” said Brian Blase, who advised Trump on health policy before leaving the White House last year. “I don’t think there are a lot of policies that came out that took revenue away from hospitals,” he added, noting that hospitals successfully sued to block Trump’s billion-dollar cut to a drug-discount program and other regulations opposed by hospitals have been similarly stalled.

Amid the historic public health threat, hospital officials are loath to renew a public battle too and criticize the administration.

“We have been very clear that we have had serious concerns with a number of other policies from the Administration, including the issues of Medicaid expansion and cuts to hospital outpatient department visits,” a spokesperson for the American Hospital Association told POLITICO. “Right now, of course, our focus is on working with the government and other stakeholders at all levels to address the current emergency.”

But some hospital leaders did express frustration on Saturday after Surgeon General Jerome Adams warned that hospitals may need to postpone elective surgeries to handle the crush of coronavirus patients.

“Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!” Adams tweeted on Saturday, adding that such procedures could further the coronavirus spread, tax medical stockpiles and put further pressure on doctors and nurses.

The message from the nation’s top doctor was seen as alarmist and premature, worrying hospital officials that it would prompt patients to postpone crucial care. “I do think it’s unfortunate what the surgeon general said,” said Kahn, adding that he hoped Adams and Gov. Andrew Cuomo, who similarly warned of the need to cancel some procedures, would walk back their statements. “I don’t think we’re anywhere near a point where we know we would have to do something like that.”

The coronavirus outbreak has served as justification of hospitals’ yearslong warnings over federal policies that the industry saw as hamstringing their finances and preparedness, executives said. Now, the same government that sought to cut pay rates and layer on new regulations is relying on hospitals as the nation’s chief defense against the pandemic.

“Governments tend to, on a day-to-day basis, underestimate the importance of the health care community and look at it not so much as an economic contribution as an economic deficit,” Raske said, emphasizing that the attitude extends well beyond the Trump administration. “That tendency hits reality in a crisis.”

Hospital leaders also have warned about the dearth of ventilators to treat the sickest patients — an issue that Verma has failed to directly address in multiple interviews, including being grilled by Fox News host Tucker Carlson on Friday night over whether hospitals will have enough.

"You know, Tucker, I don't want to make drastic predictions here, right?" Verma said. "Because this situation is changing every single day. And based on the information we have, we know that we have to be aggressive," she added, touting yesterday's moves to increase flexibility for hospitals and relax regulations.

“That was one of the most incompetent and absolutely incoherent responses to what’s going on right now,” Michael Osterholm, a University of Minnesota infectious-disease expert, told Carlson a few minutes later.

CMS did not directly respond to questions about whether there is a dearth of ventilators.

Meanwhile, hospital executives have noted the dark irony of Washington’s sudden focus on mass treatment capacity after years of efforts to crack down on hospital reimbursement prompted providers to shrink their facilities.

“I’m really worried about how, when this finally blows over, what Congress does,” said one lobbyist. “Are we actually going to learn from this?”

“We love hospitals,” countered Blase, Trump’s former health policy adviser. “Hospitals are going to be at the front lines of this and have an enormous job. But there shouldn’t be policies that give them advantages they shouldn’t have.”

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