Fact Checker: Joe Biden overstates symptoms of Iowa Medicaid

Former Vice President Joe Biden answers questions at a presidential campaign stop Jan. 2 at the National Motorcycle Muse
Former Vice President Joe Biden answers questions at a presidential campaign stop Jan. 2 at the National Motorcycle Museum in Anamosa. (Rebecca F. Miller/The Gazette)

Democratic presidential hopeful and former Vice President Joe Biden held a campaign event Jan. 2 in Anamosa, where he spoke about some of the challenges facing hospitals in Iowa.

“In your state, your governor goes ahead and privatizes Medicaid, which is why hospitals aren’t getting paid on time so they’re shutting down,” Biden said during a question-and-answer session at the event. “They’re shutting down emergency services and they’re at risk.”


Across the United States, 162 rural hospitals closed between 2005 and 2019, according to the North Carolina Rural Health Research Program at the University of North Carolina.

In 2005, nine rural hospitals nationwide closed. In 2019, the number of closures reached 19, according to data from the research program.

Graded a C

None of those closures were in Iowa. And no Iowa-based hospital has closed down its emergency services, either, according to the Iowa Hospital Association, an organization that represents all of the state’s hospitals.

But based on research and expert opinion, hospitals in Iowa are facing major challenges. According to a 2019 analysis from Chicago-based consultant Navigant, nearly 18 percent of Iowa’s hospitals — or a total of 17 — are at “high financial risk” of closure in the near future.

“Iowa hospital global financials are the worst they’ve been in 30 years,” Kirk Norris, chief executive officer of the Iowa Hospital Association, told Fact Checker.

Biden’s campaign did not provide any sourcing for the candidate’s claims on hospital closures or emergency department closures in response to the Fact Checker’s inquiry.


However, it did provide a half dozen articles from Iowa newspapers, including The Gazette, on Medicaid.

“After nearly four years of privatized Medicaid here in Iowa, the Vice President was making the point that many providers, members and policymakers have consistently been making,” a campaign spokesman said in an email. “Because of the state’s shift to this program, services for members have been cut, payments to providers have been delayed or not delivered altogether, and even two of the managed care organizations decided to leave the program because they believed it was unsustainable in its current form.

“Privatized Medicaid has been a failure in Iowa and has put at risk the financial solvency of some providers,” the spokesman said.

According to a 2018 report on hospital closures from the U.S. Government Accountability Office, rural hospitals in states that expanded Medicaid had a “substantially lower likelihood of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion.”

Expanding Medicaid in Iowa opened the door to a larger patient base for rural providers, Norris said in a Gazette report, but privatizing the program “took several hundred million” in reimbursement dollars out of community hospitals.

Iowa “privatized” its Medicaid program in early 2016, shifting the entire system from a state-run fee-for-service program to a managed care program. Under managed care, private insurance companies are contracted — and funded — by the state to oversee Medicaid members’ health coverage.

Since the switch, many health care providers have raised concerns about late or incorrect payments from the managed care organizations.

The Biden campaign pointed out recent events, in which one of the managed care organizations — Iowa Total Care — had $44 million withheld from its monthly payment from the state due to unresolved issues with payments to providers.


Norris said in September 2018 that all of Iowa’s 118 community-based hospitals are having issues receiving reimbursement from managed care organizations for the care they provide to Medicaid members, according to reporting from The Gazette that Biden’s campaign sent the Fact Checker team.

Norris said association members tell him “they’re still dealing with first-day issues that they were dealing with two years ago” and they’re spending $3 instead of the $1 it previously cost them to process claims.

Central Iowa Family Planning, an independent women’s health care provider based in Marshalltown and Grinnell, blamed the switch to managed care as the reason both clinics permanently closed in November 2016, according to the Marshalltown Times-Republican.

“There are issues with payments and reimbursement levels, to the point that there is really nothing more we can do,” Central Iowa Family Planning Executive Director Mandi Beeghly said in a statement. “They’ve killed us.”

Biden’s campaign pointed to managed care policy changes on reimbursement for emergency room care about two years ago as the source for his statement on the services in Iowa.

Effective August 2018, the managed care organizations would no longer fully reimburse emergency room care if the primary symptoms the patient reported were not an emergency, according to the Associated Press.

In addition, state officials overseeing the Medicaid program reclassified “more than 700 symptoms to non-emergency status,” the AP reported. One condition officials excluded was epigastric pain, which is a common symptom of a type of heart attack, according to the report.

“Often the only way to exclude heart attack is by running tests including an EKG,” the AP wrote. “If the tests show no heart problem, the Medicaid insurers will deny the charges saying the pain was not an emergency and the hospital won’t get paid.”


Part of Biden’s claim checks out. Iowa’s hospitals, as well as other health care providers, face late and incorrect reimbursement from the managed care organizations that oversee Iowa’s Medicaid program.


Some experts have said this is a major issue facing rural hospitals in Iowa. But ultimately it is not the sole reason those facilities are under financial strain.

Biden’s conclusion that hospitals in Iowa are closing because of Medicaid privatization is overstated. Fact Checker did find an instance of a clinic shutting down due to poor Medicaid reimbursement, but otherwise Biden was incorrect that Iowa’s hospitals and their emergency departments are closing as a result of the program.

Taking all that into account, Fact Checker gives him a C.


The Fact Checker team checks statements made by an Iowa political candidate/officeholder or a national candidate/officeholder about Iowa, or in ads that appear in our market.

Claims must be independently verifiable.

We give statements grades from A to F based on accuracy and context.

If you spot a claim you think needs checking, email us at

This Fact Checker was researched and written by Michaela Ramm of The Gazette.

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