Blogofbrew

Iowa Medicaid pays out about $8.6 billion a year. This post documents a browser suite for that ledger — three static HTML pages and four fetch scripts, now living in tools/ — and the open questions the data surfaced. Everything renders from committed JSON snapshots; every number below traces to a public URI.

Methodology: latent-space search with a frontier model

The build loop was human-executes, model-navigates. I worked with Anthropic’s Claude (Fable 5), using the model’s latent knowledge of government data ecosystems as a search heuristic over sources that no search engine indexes well: which agency families publish what, how state Socrata portals migrate, what a DSH examination schedule looks like, where CMS hides its DCAT catalog. The model proposed dataset identities and fetch code; I ran everything locally and pasted logs back; the logs falsified or confirmed; repeat.

That loop mattered because the terrain shifted mid-project. Iowa migrated data.iowa.gov off Socrata onto a new “Data Hub” in August 2025, breaking every legacy API ID. The model’s guesses about the new world were treated as hypotheses, not facts — several were wrong, and the fetch scripts grew fallback chains (hub ID → CKAN discovery → legacy Socrata → manual override) precisely because reality kept voting. The strongest example of the epistemics: an early extraction of the state’s DSH audit schedules misassigned columns, briefly manufacturing a fake “UIHC DSH collapse.” Uploading the full PDFs caught it; the corrected pages carry an explicit retraction rather than a silent edit. Latent-space search finds doors fast; only receipts open them.

Data URIs the suite runs on:

• Iowa Data Hub (all CC-BY, monthly): dataset 974 Medicaid payments by service category × month (2011→); 973 by county × month with eligibles; 975 by LTC facility × month; 939 county budgets by service area (FY2005→).
• Iowa Auditor of State DSH examinations (SPRY 2017 & 2021): legis.iowa.gov/docs/publications/ADRPT/1208822.pdf, 1518523.pdf.
• CMS Hospital Provider Cost Reports (HCRIS CMS-2552-10) via the data.cms.gov DCAT catalog — FY2012–2024 for our hospitals.
• Hospital price-transparency MRFs (45 CFR 180) discovered via each hospital’s /cms-hpt.txt — including payer-specific negotiated rates for Medicaid MCO plans.
• IRS 990s via ProPublica Nonprofit Explorer; federal single audits via the Federal Audit Clearinghouse API.
• Census ACS/decennial for population (now API-key-gated — see gripes below).

What the ledger shows

• Managed care ate the ledger. Capitation was 0% of payments through 2015; IA Health Link launched April 2016; the MCO line is now 94.1% of ~$7.6B in latest-12-month payments ($6.93B). Statewide detail by service category is FFS residue.
• Spending: CY2019 $5.73B → CY2025 $8.63B. Decomposed, growth is essentially all per-member: Polk County runs ×1.36 since 2019 on flat eligibles.
• County attribution is decaying. The county file booked 125.9% of the category file’s 2024 total, with a “Central Office” pseudo-county absorbing ~31% of dollars (4% in 2018). County-level “spending” increasingly isn’t.
• The county mental-health levy is extinct. SF 619 (2021) took statewide county MH/DD budgets from ~$134M (FY2020) to zero (FY2026); by FY2023 the statewide line was Polk.
• DSH, corrected: UIHC’s DSH received rose $29.0M → $64.8M between exam years; Broadlawns held ~$6.5–7.2M against $8.56M/yr in its audited agreements. Broadlawns’ total hospital cost rose +37% (SPRY2017→2021), UIHC +32%.
• Hospital Medicaid revenue (cost reports): UIHC $139.3M (FY2015) → $214.8M (FY2023); Adair County Memorial Hospital $1.1M (FY2012) → $4.0M (FY2024) — ×3.6.
• First look inside MCO pricing (UIHC’s 20,118-code Medicaid rate book): Iowa Total Care and Molina pay identical rates; Wellpoint ~2% lower — everyone pricing off the state fee schedule — while Medicare Advantage pays ~7× Medicaid for the same procedure.

The Adair question (open)

Adair County is the statewide per-eligible outlier: $1,577 per eligible per month across only ~1,558 eligibles — $29.5M/yr through a tiny base, with enrollment share (21% of population) perfectly normal. The obvious hypothesis was facility mix: LTC beds dominating a small denominator. Here’s the fun part: the facility-level dataset eliminated it — Adair’s five LTC facilities show ~$27K/yr in payments, because dataset 975 records FFS payments and LTC has flowed through MCO capitation since 2016. The county hospital’s cost reports add only $4.0M of Medicaid revenue. So at least ~$25M/yr attributed to Adair is invisible in every facility-level public dataset — presumably MCO-paid LTSS/waiver services to Adair-coded members, but presumably is not a finding. Also unexplained: Adair’s served/eligible ratio of 1.05, the state’s highest. What would settle it: county-level MCO encounter data (T-MSIS-derived LTSS tables), Adair County Memorial Hospital’s audited payer mix (auditor.iowa.gov filings; FAC shows the hospital under EIN 426037639), and an eligibility-group mix table. The tools are pointed; the answer isn’t in yet.

Questions the Legislative Services Agency should ask

1. Why does the State Auditor’s website block automated access? auditor.iowa.gov’s robots.txt disallows crawlers — for public audit reports. A citizen can click; a citizen’s script cannot. Public accountability documents should be bulk-accessible by design.
2. Why is county attribution collapsing into “Central Office” — and can retroactive bookings be restated to counties so the public county file stays meaningful?
3. Publish MCO encounter-based facility payments. Dataset 975 is honest FFS accounting of a world that ended in 2016. The $6.9B capitation line needs a public encounter-level companion — at minimum vendor × county × month, the shape 975 already has. (975 also lacks county/city columns; names had to be matched by string.)
4. Reconcile the public files to the CMS-64. The 2024 county-vs-category gap (125.9%) and the 2026 partial-year artifacts deserve a published crosswalk.
5. Hospital price files need enforcement follow-through. CMS has warned 500+ hospitals nationally (the Register reported an unnamed Des Moines hospital among them). In our sample: Broadlawns publishes five MRFs but with payer labels that defeat standard Medicaid filtering; Adair’s file hides behind a vendor’s .aspx endpoint. Standard-format compliance is what makes transparency machine-usable.
6. Small friction, big tax: the Census API silently began requiring keys, returning HTML error pages to JSON clients. Every such piece of friction compounds against citizen audit.

Mental health and hospice: surges worth a look

From the 990 series (org-wide revenue, not Medicaid-specific — leads, not verdicts): Johnson County’s crisis infrastructure grew explosively since 2019 — CommUnity Crisis Services ×2.96, Shelter House ×2.36, Abbe Center ×2.25 — consistent with the CCBHC/988/ARPA era, and worth asking which funding is structural versus expiring. Hospice and home health tell a harder story: EveryStep (VNS of Iowa) grew ×2.81 while running a −15.2% margin, and WesleyLife is at −37.7% with expenses growing ×1.17 against revenue ×0.85 — the post-acute cost squeeze in one line.

Nonprofits that could use assistance (expenses outgrowing revenue over their last three filings, or negative margins — read the filings via the links on the county panel): WesleyLife, EveryStep, Link Associates (rev ×0.94 vs exp ×1.13), Lutheran Services in Iowa (×0.94 vs ×1.15), Candeo, Orchard Place, United Action for Youth, Goodwill of the Heartland — and CommUnity, whose ×2.96 growth at breakeven is the classic scaling-faster-than-controls pattern. Two artifacts flagged rather than alleged: Easterseals Iowa’s +97% “margin” looks like a foundation-arm filing split, and Genesis Development’s numbers are a merger wind-down.

The tools

iowa-medicaid.html — statewide explorer (baselines to 2011, era-split charts, per-eligible/per-capita sorting). county-panel.html — Polk/Johnson/Adair: levy extinction, debt service, org 990s + single audits, registered-address maps, the Adair story section that recomputes its own verdict as data lands. hospitals.html — Broadlawns/UIHC/Adair: corrected DSH trail, cost trajectories, Medicaid share. Refresh scripts (refresh_iowa_medicaid.py, fetch_polk_orgs.py, fetch_hospital_prices.py) rebuild every JSON from source, print their own diagnostics, and survived one portal migration already. Licenses: Iowa Data Hub CC-BY 4.0; federal sources public domain; page skeletons after simonw/tools.

Corrections welcome — that’s the point. Every figure above has a JSON snapshot and a source URI behind it, and the one error we caught mid-build is documented on the page it touched.