Stamping Out Welfare Fraud

Fox 2 from St. Louis reports on Auditor Schweich’s findings of welfare fraud through the use of welfare cards in different states – and, in at least one case, the Virgin Islands. Worth noting – Rep. Wanda Brown filed HB 1861 last week to put an end to this practice and I was glad to be the first co-sponsor.

School-Based Health Clinics Work

On Monday, the House Committee on Government Oversight and Accountability passed HB 1052, a bill to encourage the construction of school-based health care clinics in high-poverty school districts. Many other states, most notably Texas, have robust school-based clinic programs. The following is a memo from my Legislative Assistant Emily Walker summarizing research on these clinics. Conclusions: they work to save money, reduce unnecessary ER visits, and improve the health and education outcomes of students in schools where these clinics exist. 

To:       Representative Barnes

From:   Emily Walker

Re:       School Based Health Clinics

Date:   February 6, 2014


Question:        What are the value of School Based Health Clinics based on academic studies and real world data?


            School Based Health Centers (SBHCs) have developed in the past three decades as a solution to health care access problems in younger populations.  These in-school clinics help to “overcome utilization barriers in a way not previously documented in other clinical settings, even when serving populations that suffer from significant health disparities.”[1] Based on census data collected by the School-Based Health Alliance for 2010-2011, there were 1381 school based clinics that provided primary care and responded to the surveys.[2] SBHCs are found in a variety of communities: 54.2% in urban areas, 27.8% rural areas, 18.0% suburban areas.[3]  Of the responding clinics, 94.4% are located within school buildings.[4] The numbers of these clinics are growing and Missouri already has four located within our state.[5]

            There is no set funding or structured mechanisms for SBHCs.  Financing may come from a variety of sources and control comes from multiple levels (private sector, local government, state government, etc.)  Other states have successfully implemented these clinics on a state level.  Texas recently passed an expansion measure in 2009 to further support SBHCs.[6] HB 281 was a bipartisan bill passed unopposed in the House Public Education and Senate Education committees and signed into law by Governor Perry.[7]  This expansion of the program included stabilized and increased grant funding for the programs.[8]  According to the Census data collected by the School-Based Health Alliance, Texas had 87 school-based health clinics at the time of the survey.[9]

            There are many benefits to the school-based health clinic system.  These clinics have consistently shown decreases in emergency department visits, increases in primary care access, increases in immunizations, and better quality of health care for children who traditionally lack health care resources.  SBHCs knock down many of the barriers that children from high-risk families often battle, including: lack of private health insurance, transportation to appointments, parental absence from work, lack of awareness, and other stressors that keep children away from health professionals.[10] Not only do these programs give children access to health care, the ultimate goal of the clinics serves the ultimate goal of education programs.  As Adams and Johnson explain, “the program is aimed at improving school attendance and classroom performance and the longer-term prospects for these children as they mature”[11] 

            Numerous studies have found the cost saving measures that school-based clinics provide for public insurance programs. In Adams and Johnson’s article, An Elementary School-Based Health Clinic: Can it Reduce Medicaid Costs?, the authors answered the title question in the affirmative.[12]  This study compared children served by a school-based clinic to demographically similar children who did not have access to the same kind of clinic.[13]  There were no significant differences between the groups before the clinic opened, but two years after its opening, the children with access to the clinic had significantly lower instances of inpatient visits, non emergency department transportation, drug, and emergency department Medicaid expenses.[14]  These lower instances of high cost health care items meant that the school-based clinic helped to curb costly health care mechanisms for the children who had access to the SBHC.

            Another study also examined the affect of school-based clinics on the frequency of emergency department visits.  In Young, D’angelo, and Davis’ 2001 article Impact of a School-Based Health Center on Emergency Department Use by Elementary School Students, the authors wrote that emergency room visits are often non-urgent and have the negative effects of increasing medical costs and fragmenting health care.[15]  In their study, the authors examined elementary aged children (5-12) from an inner city neighborhood.[16]  The clinic served a school that had a student population of 95% of the population on free/reduced lunch and 60% African American/40% White.[17]  This study used a retrospective audit of emergency department records that compared the year before implementation of a school-based clinic to the year after its inception.[18] There was a significant drop in emergency room visits after the school-based clinic was introduced to the school.[19]  The results of this study show that SBHCs help to decrease non-urgent emergency department visits, and therefore the higher costs of these visits.

            Key, Washington, and Hulsey provided their findings of lesser emergency department visits by adolescents enrolled in SBHCs into their 2002 article, Reduced Emergency Department Utilization Associated with School-Based Clinic Enrollment.  This was another retrospective cohort study that examined emergency department utilization rates before and after adolescents enrolled in a SBHC.[20]  The subject school was an urban, public high school that’s student population was made up of 80% free/reduced lunch recipients and 99% African American.[21] The study showed a decrease in the emergency department visit rate for both groups from the base year, but this decrease was only statistically significant for the students who chose to enroll in the SBHC (enrollees had a 41% decrease of emergency room visits after enrolling in the clinic).[22]  The authors noted that because the study compared a population with prior emergency room use and then recorded the changes following the enrollment in a SBHC, the SBHC should be attributed as the cause of the decrease.[23]

            Beyond the scope of saving money on decreased emergency room visits, SBHCs serve other important interests as well.  One major benefit to note is the ability of SBHCs to help with vaccination rates in adolescents. In the article Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery, the authors performed a study to determine if SBHCs can improve rates of immunizations among at risk children and adolescent populations.[24] The study was a retrospective cohort analysis of children and adolescents who were split into groups that received health care from either a Denver SBHC or Community Health Center (CHC).[25]  For most types of vaccinations, children and adolescents were more likely to be up-to-date on their immunizations if they received health care from SBHCs.[26]  Along with this, for vaccines that require multiple doses over a set period of time, SBHCs were more likely to guarantee children received all doses.[27]  The authors noted a variety of reasons for why SHBCs are better for vaccinations, including: easier access to care, reminders to come back for care are easier, the tracking system is easier within the school system, many SBHCs see patients without any payment requirements, parents do not have to leave work, and students do not have to leave campus for the care.[28]

            Finally, a more recent study addresses all of the issues discussed above and the overall strong benefits of SBHCs.  In the article School-Based Health Centers: Improving Access and Quality to Care for Low Income Adolescents, the authors wanted to examine all of the advantages of SBHCs.[29] This was a retrospective cohort study that tracked the use of health care and markers of quality of care for adolescents enrolled in SBHCs compared to adolescents who used other community care entities.[30]  The SBHCs helped to increase uninsured adolescents access to care for primary health care.[31]  This increase in access to care through SBHCs led adolescents to report a higher likelihood to have three or more primary care visits, less emergency department visits, more health maintenance visits, and a higher likelihood to receive a flu vaccine, a tetanus booster, and a Hepatitis B vaccine.[32]  The authors of this study strongly established that SBHCs provide underserved adolescents and children with better access to care and an overall higher quality of health care than traditional community health systems do.

            There are multiple studies available to show the benefits of SBHCs to serve populations of children and adolescents that traditionally have not received quality health care.  These clinics have statistically shown they can reduce Medicaid expenditures through better preventive care measures, they increase immunization rates, and overall, they provide higher quality of care for a population that is often underserved.

[1] Steven Federico, et. al., Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery, 100:9 American Journal of Public Health,1630-1634 (2010).

[2], 2010-2011: Census Report of School-Based Health Centers, School Based Health Alliance, 2012, (last visited February 6, 2014).

[3] Id.

[4] Id.

[5] Id.

[6], Legislative Efforts, Texas Association of School-Based Health Centers, 2009, (last visited February 6, 2014).

[7] Id.

[8] Id.

[9] 2010-2011: Census Report of School-Based Health Centers.

[10] Thomas Young, et. al., Impact of a School-Based Health Center on Emergency Department Use by Elementary School Students, 71:5 Journal of School Health, 196 (2001).

[11] E. Kathleen Adams and Veda Johnson, An Elementary School-Based Health Clinic: Can it Reduce Medicaid Costs?, 105 Pediatrics, 780-788 (2000).

[12] Id.

[13] Id.

[14] Id.

[15] Young, D’angelo, and Davis.

[16] Id.

[17] Id.

[18] Id.

[19] Id.

[20] Janice Key M.D., E. Camille Washington, M.D., Thomas C. Hulsey M.S.P.H., Sc. D., Reduced Emergency Department Utilization Associated with School-Based Clinic Enrollment, 30:4 Journal of Adolescent Health, 273-278 (2002).

[21] Id.

[22] Id.

[23] Id.

[24] Id.

[25] Id.

[26] Id.

[27] Id.

[28] Id.

[29] Mandy A. Allison, MD, MSPH, et al. School-Based Health Centers—Improving Access and Quality of Care for Law-Income Adolescents, 120:4 Pediatrics, 887-894 (2007).

[30] Id.

[31] Id.

[32] Id.

Education Establishment Asks State Board to Pretend It Has a Magic Wand

On Tuesday, the state’s education establishment joined together to offer a “plan” to fix struggling schools in our state. Their plan is simple. It asks the State Board of Education to wave its magic wand and declare a struggling district cured through a simple administrative pronouncement. Here’s how it would work. Once the State Board declared a district unaccredited, the district could enter into a contract with the State Board promising to improve… and presto!, the district would magically be declared provisionally accredited.

This plan doesn’t require any evidence of actual improvement, and it makes a joke of the accreditation process. It changes the school accreditation process from one which requires accountability to one which perpetuates failure without consequence. It’s geared toward protecting existing power structures rather than ensuring substantive changes to improve the lives of Missouri families with students trapped in struggling schools. In addition, it arguably violates the letter of existing state laws and undoubtedly violates the intent of SB 125, the education reform bill I helped pass just last year.

In recent years, the State Board has shown it has the political courage to make difficult decisions regarding struggling districts, and it’s my hope that the Board will continue that tradition. 

Kelo Revisited – They Didn’t Even Build It

Eight years ago the Supreme Court ruled that government could take your home for the purpose of increasing tax revenue by giving it to a big business or developer. The case, Kelo v. New London, caused an outcry from right-and-left.

The Weekly Standard goes back to New London this week and discovers that, even though the government stole Suzette Kelo’s house, the big developer who they wanted to give it to never fulfilled their promises. 

Zip Code Should Not Determine Destiny

Increasing Opportunity for Low-Income Students
A child’s zip code should not determine their destiny. For more than two centuries, America has been the greatest nation in history because of the freedoms guaranteed by our Constitution. Indeed, Americans are the most free to realize their full potential through their own “pursuit of happiness.”The up-by-the-bootstraps story is fundamental to the American identity. Regardless of what you think of President Obama’s politics, his presidency is a living testament to upward mobility in America. The son of a Kenyan immigrant and a Kansas farm-girl, there aren’t many places in the world where a man with that background could become president. The same can be said of House Speaker John Boehner, who was born to a family of modest means. These stories are, of course, not limited to elected officials. Consider Missouri’s own Sam Walton, or Jack Dorsey of St. Louis, founder of Twitter, among other countless examples.Over the last 40 years, however, the American dream has been slipping away in some zip codes. A recent Harvard study found that children born in poverty in Kansas City and St. Louis are approximately 50 percent less likely to eventually earn a middle to upper-class income than their same aged peers born in poverty in mid-Missouri.Liberals see stats like these and oft ask how government can ensure an “equality of stuff.” The left’s solution is generally geared towards centralized power and a redistribution of wealth from cradle-to-grave to make society more equal. What the progressive often believes works best is more rules, more organization, and more government money.

Conservatives understand that inequality alone is not a bad thing. (In fact, recent history has shown that equality increases during a recession.) Economic activity is not a zero-sum game and “equality of stuff” is neither just nor possible. The world learned that lesson in the Cold War. The Soviet Union was perhaps the most unequal society in history – the vast majority of the population lived in poverty, while the politically powerful enjoyed the fruits of their connections. We know how the Cold War ended. To paraphrase Reagan, “We won. They lost.”

Conservatives, by contrast, ask how government can better ensure “equality of opportunity.” The best way to ensure equal opportunity is for government to create and enforce a basic framework of rules that empower citizens to reach their potential. And while increased inequality is not necessarily a bad thing if the entire economy is improving, social mobility matters.

The conflicting philosophies of conservatives and liberals is clear in the contrasting approaches to the challenge of education in high poverty neighborhoods. Liberals tend to focus on increased funding and more centralized control. Sometimes their logic seems more focused on buildings and protecting existing power structures than helping real-life children.

House Bill 1579, which I have sponsored, takes a more comprehensive and conservative approach to improving education in high-poverty struggling school districts. It does so by empowering families in these communities to choose the school which will work best for them – as they see it, not as someone else does. The bill would:

  1. Encourage the rapid expansion of high-performing charter schools;
  2. Create scholarships for students in low-income families to attend the same schools as students from wealthy families, on the condition that the school they choose abides by the same requirements as traditional public schools and agrees not to compel any scholarship recipient to attend a religious class or ceremony;
  3. Protect the freedom these families have under current law to choose a different traditional public school, but allows “receiving schools” to place reasonable restrictions on transfers to ensure there is enough classroom space to help; and
  4. Allow students to choose courses in virtual education as an alternative to brick-and-mortar schools.
Beyond protecting and increasing these families’ freedom to choose their own path, HB 1579 would help improve struggling schools by creating a fund to pay bonuses to high-performing teachers and a more equitable transfer funding formula to prevent potential bankruptcies.I anticipate that discussions on big education legislation this year will take a long and winding path. My focus will be on increasing opportunities for families in struggling districts to pursue their own happiness, and not be held back by the arbitrary silo of an unfortunate zip-code, and I’ll do my best to ensure that the principles and policies included in HB 1579 are included in any legislation that makes it to the finish line.

Plan for Fulton State Hospital Passes Constitutional Test

Rep. Chris Kelly (D-Columbia) argues that the current proposal to build a new state mental hospital in Fulton is unconstitutional. I disagree. Since 1962, the Missouri Supreme Court has ruled that our state constitution allows construction projects which are subject to annual appropriations and thereby impose no binding legal obligations on the state without a constitutional amendment. This is the process by which the state has built or improved 16 state buildings, including the Truman Building, the Secretary of State’s office, the new JCCC, and DNR’s Lewis & Clark Building. It was constitutional for each of those 16 projects, and it’s constitutional now.

The Good, the Bad, and the Ugly from Gov. Nixon’s Budget

Rep. Jay Barnes’ Capitol Report, Friday, January 24, 2014

The Good, the Bad, and the Ugly of Gov. Nixon’s Unbalanced Budget Proposal

Ever spent an hour filling up a grocery cart only to discover at checkout that you forgot your wallet at home? That’s the situation that came to mind Tuesday while listening to Gov. Nixon’s State of the State address. In total, Gov. Nixon promised $493 million in new education funding. Unfortunately, this budget is just like the grocery cart filled on an empty stomach – with no wallet in sight. While Gov. Nixon touts our state’s AAA credit rating, this year’s budget proposal is $310 million in the red.

Gov. Nixon has picked up many tricks in his 27 year political career. As governor, he knows there’s little downside to proposing an unbalanced budget. It puts the legislature in a box: we can either make the tough choices necessary to pass a balanced budget; or, we can pass his unbalanced budget.

If we make the tough choices, Gov. Nixon will use his bully pulpit to blame Republicans for not meeting his impossible and irresponsible education funding promises. If we pass his unbalanced proposal, we abdicate our constitutional duty and allow Gov. Nixon to use the withholding power to usurp the budget responsibilities assigned to the legislature by the state constitution.

For me, the choice is easy. The legislature must meet our constitutional responsibility to fix Gov. Nixon’s unbalanced budget proposal – even if it requires difficult decisions, and even though it’s a political set-up.

A quick rundown:

The Good - Gov. Nixon proposed a 3 percent pay raise, renewal of the state match for deferred compensation, and steady health insurance premiums for state employees. These are much needed improvements and have my full support. Gov. Nixon’s call for increased education funding also has my support – but those increases must be measured by reality and coupled with real accountability, not the empty soundbites offered by Gov. Nixon in Tuesday’s speech.

The Bad - Gov. Nixon’s budget bets on the passage of Medicaid and tax amnesty legislation which may – or may not – happen. This adds approximately $150 million in revenues to the bottom line, but requires legislative action that is iffy at this point. Gov. Nixon also abandoned the consensus revenue estimate generated by the House, Senate, and non-partisan economists from Mizzou. This gubernatorial accounting convenience added another $160 million in hypothetical revenues to the bottom line and led Sen. Budget Chairman Kurt Schaefer to call Gov. Nixon’s budget “absolute political fiction.”

The Ugly - Gov. Nixon proposed $350k to create a state office in Washington, D.C., but we already have eight members of Congress and two Senators ready, willing, and able to represent Missourians there. We don’t need a state office on top.

Supporting State Employees Who Care for Foster Children
Every child deserves a chance and a loving environment. Far too often, however, children in foster care never find a stable home. I’ve sponsored House Bill 1054 to provide support to state employees who volunteer to care for foster children by making shared-leave time available for foster children on the same terms that it’s available for adopted or step-children. The bill was heard Tuesday in a House committee and I’m hopeful that it will be put on fast-track status.
Investing in Lincoln University
On Monday, a group of local leaders joined Sen. Kehoe and Gov. Nixon for the announcement of a proposed $10 million investment to re-model the current, but soon to be “old” St. Mary’s to convert it to use for Lincoln’s nursing program, culinary arts, state offices, and other potential uses. As Sen. Kehoe explained, St. Mary’s is more than just a building. It’s a cornerstone of the community where many of us have our most precious memories. It’s the place where all of my children were born. As St. Mary’s moves into a new facility, it’s important that we find a great use for the historic campus.Monday’s announcement is a good investment for Missouri and great news for our community. For state taxpayers, it’s an investment in quality health care education at an affordable price. For the community, it will help ensure that the historic property is put to important use for generations to come.

How You Can Help Check Arbitrary Executive Power

An Amendment to Check the Executive Power to Promulgate Excessive Regulations  

  • Shall the Constitution of Missouri be amended to guarantee a legislative check on the executive power to promulgate administrative rules which are unlawful, arbitrary and capricious, dangerous to the public, excessive, or inconsistent with the original purpose of the law, with all such legislative decisions subject to the check of judicial review? 

That’s the question likely headed to your ballot this fall.

Both the U.S. and our state constitution are designed to limit governmental power. The Bill of Rights limits government power by guaranteeing zones of freedom for citizens. The constitution itself limits power through an intricate system of both vertical and horizontal checks-and-balances. Power is checked vertically through our system of federalism. And it’s checked horizontally through features like judicial review, confirmation of appointments, veto power, and much more.

Unfortunately, our Founders never envisioned the rise of the modern administrative state where policy-making authority is wielded ever more often by executive agencies rather than legislatures. In Missouri, the Joint Committee on Administrative Rules was created decades ago to check the governor’s power regarding administrative rules. Under current law, the committee checks executive power – but only with the agreement of the governor. The problem is plain. How good is a check on government power if it requires the consent of the branch which is supposed to be checked? In reality, if the governor is unwilling to cooperate, JCAR can be more like a speed-bump than a road-block for overreaching or arbitrary and capricious regulations.

In Washington, there is nothing like JCAR to check the president’s power to promulgate administrative rules which Congress believes are inconsistent with the statutes which give them power. That’s why President Obama bragged to Democrats this week that he wouldn’t need Congress for many of the large policy initiatives of his second term. “I’ve got a pen, and I’ve got a phone,” he’s reported as saying – indicating that he’s going to govern by administrative rules and executive orders rather than cooperation with Congress.

House Joint Resolution  57, which I have sponsored, would strengthen JCAR’s ability to check executive power by eliminating the requirement that the governor cooperate. By putting JCAR in the Missouri Constitution, with its decisions subject to judicial review, we ensure that Missouri, unlike Washington D.C., doesn’t suffer from a run-away executive branch.

I expect floor debate on this important resolution to take place sometime in the next few weeks and hope to have your support if it makes the ballot this fall.

Helping Students Prepare for Their Future
Education is a contentious issue in the state capitol. While most agree on the goal (a system that gives every kid a chance to succeed in life), there are many different ideas on how to get there. I believe the best way to improve education is to give children and their parents as many options as possible – and to let families decide what works best for them. We should attach education funding to real life children with hopes and dreams and encourage schools to compete for students. Others favor a more centralized model where administrators make most decisions and families have fewer choices. That philosophical difference has been and will continue to be debated.

This week, however, I sponsored education legislation which I believe should garner broad support and bridge the gap between the “Reformer” and “Establishment” camps.House Bill 1357 would help Missouri students (and their parents) prepare for their future by requiring schools to facilitate a personal plan of study to achieve their future goals. For some students, that will mean creating a schedule of classes and extracurricular activities to assist them in gaining admission to college. For others, it will mean vocational training to learn a skill which can lead to a career. The idea is to encourage students to set education and career goals – and then help them design a path to get there. Children with goals and plans are more likely to succeed. Indeed, anyone with a goal AND a plan is more likely to succeed in an endeavor.


House Committee to Investigate Execution Protocol of Department of Corrections

The House Committee on Government Oversight and Accountability will hold a hearing on the state’s execution protocol on Tuesday, January 22 at 2:00 p.m.

Regardless of what anyone thinks of the death penalty, everyone should agree that it must be carried out according to the requirements of the Constitution and laws of our state. 

The hearing will focus on two areas of the Department of Corrections’ execution process. 

First, the committee will seek the standards, if any, that the Department has for determining whether the condemned has had all of their constitutional appeals determined by the appropriate courts.

This inquiry is the result of a recent dissenting opinion filed by Judge Kermit Bye in the wake of Missouri’s last execution. In the late December 2013 opinion, Judge Bye wrote:

At approximately 10:52 p.m. on December 11, 2013, Missouri executed Allen Nicklasson before this court had completed its review of Nicklasson’s request for a stay of his execution, a request he brought in a pending action challenging the constitutionality of Missouri’s execution protocol. That bears repeating. Missouri put Nicklasson to death before the federal courts had a final say on whether doing so violated the federal constitution.

Second, the committee will seek information on the Department’s process for determining the new drug it would use for executions, including allegations that the drug was obtained by an unlicensed pharmacy. 

Boeing RFP Response from Missouri

The Department of Economic Development responded late this afternoon with a box of documents relating to the state of Missouri’s response to Boeing’s request for RFP for production of the 777x.

I’ve attached the most relevant documents to this post. 

It’s interesting that DED Director Mike Downing leads off DED’s RFP response with a paragraph highlighting Missouri’s tax climate. I agree. Taxes matter most. So let’s enact broad-based tax relief to encourage job growth throughout the economy – not just to the special and privileged few.

It’s also worth noting that these are opening offers. A final deal could have looked a little bit different. The cost to taxpayers could have been higher. For example, Gov. Nixon had greater authority to negotiate on BUILD benefits. At the same time, the cost could have ended up being lower as well – for instance, if Boeing did not create as many jobs as contemplated in the offers below.    

Credit where it’s due: I’ve frequently been a critic of DED and our so-called jobs tax credits. However, DED has always been very cooperative and timely with document requests. They were again this time. In addition, regardless of whether you think the Boeing subsidy legislation was good public policy, the documents provided show that DED exhibited great competence in putting this package together in a very short time period for Boeing.

  1. Gov Nixon Letter
  2. Scenerio 1 – Full Project
  3. Scenerio 2a – Wing Project
  4. Scenerio 2b – Fuselage Project
  5. Power Point
  6. St. Louis County Summary
  7. DED Program Summary Documents