By Chris Van Gorder

I have been in hospital and healthcare administration for almost 50 years, and I've seen the hospital financial house of cards start to crumble. I'm afraid that if current discussions in Washington come to fruition, the cards will finally fall and start a domino effect that will impact every hospital in the U.S.

Many hospitals are already failing financially as evidenced by rural hospitals closing programs, filing for bankruptcy, or closing outright. Urban safety-net hospitals are also being impacted with many -- if not most -- operating in the red. Some are closing or moving out of underserved communities. And yet, Congress is considering cuts to Medicaid and a variety of supplemental reimbursement programs that would be catastrophic. This will only be exacerbated by tariffs driving up costs, unfunded mandates from the states and federal government, and over-regulation of health facilities.

As many readers are aware, reimbursement from Medicare and Medicaid does not cover the cost of care today. Government reimbursement has not kept up with inflation, much less the costs hospitals pay for pharmaceuticals, supplies, energy, and even our dedicated staff and clinicians. Over the decades that I have worked in healthcare administration, these costs have been made up by cost-shifting to commercial insurance companies. Former Governor Arnold Schwarzenegger (R-Calif.) called that the "hidden tax" -- many thanks to all the employers and patients who subsidize government underpayments by buying their own private insurance.

But as we face an aging population and expanded Medicaid eligibility in some states, what used to be a minority of patients has become the majority, especially for rural and safety-net hospitals that serve an uninsured or government-insured population. Meanwhile, the percentage of commercially insured patients in these areas has declined. As a result, hospitals with a majority of Medicare and Medicaid patients are failing financially.

Now Congress is looking at ways to cut costs, and is considering ways to reduce Medicaid spending and supplemental reimbursement programs, like provider fees, even more. The House has asked its Energy and Commerce Committee to find $880 billion in cost cuts over the next 10 years. It's hard to see how that will be accomplished without significant reductions to Medicaid -- a program that already underfunds the actual cost of care even when adding state and federal combined reimbursement as well as other patchwork financing. Cuts to any or all of these programs will put many hospitals in an unsustainable financial position.

In all my years doing this work, I have never been as concerned as I am today.

To date, the piece of my system that has a favorable payer mix -- enough commercially insured patients to offset government-insured patients -- subsidizes our safety-net hospitals to keep them open and serving patients in their communities. But government reimbursement through Medicare and Medicaid has become so poor in recent years that physicians who serve my safety-net hospitals have asked for financial subsidies; they no longer can recruit new nor replace retiring physicians. Without physicians, these hospitals may be forced to close.

My safety-net hospitals are not unique. If Congress reduces reimbursement further, forces more patients into being uninsured, or reduces and eliminates Medicaid supplemental reimbursements, safety-net hospitals nationwide will have no choice but to shut down programs or close completely. Health systems will no longer have the funding to subsidize their safety-net hospitals and support the physicians who are willing to work in those communities. Like many hospital leaders, I am already developing contingency plans to deal with this potential cut in reimbursement. None of the options are positive. Every option will adversely impact our patients, staff, physicians, and community.

Congress, please wake up. The writing is already on the wall. Look at the rural hospitals. Look at the abysmal finances of safety-net hospitals. Any further cuts will cause the entire house of cards to collapse.

Chris Van Gorder is president and CEO of Scripps Health in San Diego.