David Dillon, vice president of public and media relations for the hospital association, said it’s ironic that Republicans who want to “repeal and replace” the Affordable Care Act, commonly known as Obamacare, have written a bill that provides more money to states that embraced the law’s Medicaid expansion than those led by conservative Republicans who rejected it.

“Assuming that you want to treat everyone equally then doing this is a clear way of not treating all states equally,” Dillon said. “It in fact penalizes states that didn’t expand Medicaid.”

The Republican bill passed the U.S. House last month in a party-line vote and is now being considered by the Senate. The rollback of Obamacare’s Medicaid expansion has been a point of contention in the repeal talks on Capitol Hill because some Republican governors accepted the federal expansion money starting in 2014 and want it to keep flowing now that their Medicaid programs are covering more people.

Senate Majority Leader Mitch McConnell has proposed a three-year phaseout of the money from 2020 to 2023, but The Hill reported last week  that some Republican senators are seeking a “glidepath” of at least seven years.

Either way, Dillon said, non-expansion states would be shorted because of how the GOP bill is structured. It goes farther than just repealing Obamacare’s expansion of Medicaid to low-income adults and would, for the first time, impose per-person caps on the amount of federal dollars flowing into the traditional Medicaid program, which mostly covers children, pregnant women, the elderly and people with disabilities.

Because the caps would be based on 2016 Medicaid spending, the hospital association’s study found that by 2025 the federal government would be spending $1,936 per capita in Medicaid expansion states versus $1,158 per capita in non-expansion states, including Missouri and Kansas.

“In essence (that’s) rewarding the states that adopted the Medicaid expansion by continuing to subsidize that expansion for at least a decade,” Dillon said.

The effect of the lagging Medicaid payments will be felt most heavily in rural areas, Dillon said, where older populations, higher rates of poverty and chronic disease and less employer-sponsored insurance make people more reliant on Medicaid.

A Georgetown University study published this month found that 41 percent of children and 13 percent of adults in non-metro areas of Missouri were on Medicaid in 2015, versus 30 percent of children and 8 percent of adults in metro areas. The differences were similar in Kansas.

“Historically it’s been a significant problem for rural hospitals that we didn’t expand Medicaid and it will continue to be,” Dillon said.

The AHCA provides $10 billion over five years to help the 19 non-expansion states, but Dillon said that’s “wholly inadequate” given that the bill falls $680 billion short of equalizing them with the expansion states. Also, Missouri hospitals alone perform a total of about $1.2 billion in uncompensated care each year.

The office of U.S. Sen. Roy Blunt, a Republican from Missouri, declined to comment on the study. The office of U.S. Sen. Claire McCaskill, a Democrat, released a statement that called Jefferson City’s failure to expand Medicaid coupled with the AHCA’s changes to pre-existing condition protections a “one-two punch in the gut for Missouri families.”