The Ledger

27 million dollars a day: that is what Texas hospitals started losing in Medicaid funding this week, and a safety-net hospital CEO says the fallout would be “catastrophic.” The Centers for Medicare and Medicaid Services (CMS) has withheld approval of three Texas Medicaid directed payment programs, worth roughly 9.8 billion dollars for the state’s 2027 fiscal year, with the bulk of the impasse tied to the Comprehensive Hospital Increase Reimbursement Program (CHIRP), which pays hospitals the difference between Medicaid rates and their actual cost of care; CMS has questioned how local Texas jurisdictions calculate the hospital taxes that fund the state’s matching share, and the standoff has run since at least a Governor Abbott letter to HHS Secretary Robert F. Kennedy Jr. on August 7, 2026. The Texas Hospital Association says the state’s new fiscal year, which began September 1, 2026, opened with the programs still unfunded, warning that “no industry can withstand 27 million dollars in losses per day”; in Houston alone, Harris Health estimates it stands to lose at least 258 million dollars, with the wider region losing as much as 1.4 billion dollars next year. Harris Health CEO Dr. Esmaeil Porsa said September 4, 2026 that “the impacts would be catastrophic for Texas’ safety-net healthcare system” and that the system “would be forced to make difficult decisions about maintaining critical services if this impasse continues.” Confidence: High. This run reviewed the Texas Hospital Association’s own statement directly. Sources: Texas Hospitals Face $27M Per Day Impact, Texas Hospital Association, Texas hospitals say they’re losing $27 million a day in Medicaid funding, High Plains Public Radio, Texas hospitals to lose $27 million in Medicaid funding daily, The Texas Tribune.

247 million dollars: that is the outstanding bond debt an Oklahoma hospital system is racing to refinance after missing a September 1 payment, one notch above a rating agency’s default grade. Norman Regional Health System, a junk-rated Oklahoma system with 247.45 million dollars in outstanding revenue bonds as of mid-2025, failed to make a 7.1 million dollar principal and 4.9 million dollar interest payment due September 1, 2026; bondholders agreed to waive the technical default while the system arranges roughly 40 million dollars in interim financing, which it expects to close by September 15. S&P Global Ratings downgraded the system to CC from CCC on August 31, 2026, and placed it on CreditWatch for a possible further cut to D, saying Norman Regional “has effectively exhausted its financial flexibility absent an external source of funds”; Moody’s had separately downgraded the system to Caa2 in 2025, citing management turnover and a severe cash decline. Norman Regional CEO Aaron Boyd said the ability to line up financing reflects “positive year-over-year operating results and stakeholder confidence in the turnaround plan,” and the system has also put out a request for proposals seeking a potential sale or partner. Confidence: High. This run reviewed trade press reporting citing S&P’s and Moody’s own rating actions directly. Sources: Oklahoma health system works to avoid bond default, Bond Buyer, Moody’s downgrades Oklahoma health system’s rating, Becker’s Hospital Review, Norman Regional Hospital revenue bonds downgraded to “junk,” HealthLeaders Media.

600 million dollars: that is what a Sioux Falls nonprofit system committed to Minnesota facilities as the price of finalizing a merger that brings it into the Twin Cities for the first time. Sanford Health completed its merger with North Memorial Health on September 1, 2026, forming a single nonprofit system of 61,000 employees, 60 hospitals and 310 clinic locations serving about 2.5 million patients, after Minnesota Attorney General Keith Ellison signed off under a 10-year oversight agreement. Sanford committed more than 600 million dollars in Minnesota investment over the next decade, including about 100 million dollars to modernize North Memorial’s Robbinsdale Hospital and preserve its Level I trauma center status, and about 500 million dollars to expand Maple Grove Hospital; the oversight agreement also requires Sanford to honor existing collective-bargaining agreements and retain employees in good standing. Confidence: High. This run reviewed Sanford Health’s own announcement directly. Sources: Sanford Health, North Memorial Health complete partnership, Sanford Health News, Sanford Health finalizes merger with North Memorial Health, Chief Healthcare Executive.

71 percent: that is the share of Louisiana’s commercially insured residents whose prescriptions flow through a pharmacy middleman that a second state attorney general just accused of illegal price-fixing. Louisiana Attorney General Liz Murrill sued Express Scripts and its Ascent Health Services affiliate on August 30, 2026, alleging Express Scripts entered an unlawful 2019 agreement with rival pharmacy benefit manager (PBM) Prime Therapeutics to coordinate pharmacy reimbursement rates, a scheme the state says let Express Scripts “drive up drug costs, squeeze independent pharmacies, and limit patient choice”; the suit follows Florida Attorney General James Uthmeier’s own price-fixing suit against the same two companies, announced August 27-28, 2026 in Polk County circuit court, which says reimbursement rates on some drugs plunged by as much as 80 percent for Florida pharmacies. Both suits allege the 2019 Prime-Express Scripts “collaboration” let Prime adopt Express Scripts’ lower rates, and both seek civil penalties, damages and court orders ending the arrangement; Murrill’s office separately reached a 45 million dollar settlement with CVS Health’s Caremark in February over related conduct. Confidence: High. This run reviewed both attorneys general’s own press releases directly. Sources: Attorney General James Uthmeier Takes Legal Action Against Prime Therapeutics and Express Scripts for Price-Fixing Scheme, Florida Attorney General, Attorney General Murrill Fights Back Against PBM Power Grab, Louisiana Department of Justice, Florida attorney general sues PBMs Express Scripts, Prime over alleged price fixing, Healthcare Dive.

THE DEAL SHEET

This run’s scan of FTC and DOJ merger actions and state transaction-review dockets found no new healthcare antitrust complaints or consent orders in the last 24 to 48 hours beyond the state-level PBM suits covered above. A frontier check on workers’ compensation medical costs, a Ledger branch not touched in the last three issues, found a new California Workers’ Compensation Insurance Rating Bureau report on shifting medical-cost drivers (published this week) but no dated transaction or funding event in this window. An open-ended scan surfaced the growing state attorney general campaign against Express Scripts and Prime Therapeutics, covered above, as the window’s most consequential legal-financial story outside the Deal Sheet.