Category Archives: Gov’t Oversight and Accountability

Rep. Keith Frederick Medicaid Transformation Proposal

Rep. Keith Frederick will present language similar to HB 608 from 2013 this afternoon before the House Interim Committee on Medicaid Transformation.

The updated version of that legislation can be found here:

Rep Frederick Medicaid Pilot

Schedule for House Interim Committee on Medicaid Transformation

Here is the schedule for the House Interim Committee on Medicaid Transformation. The Committee will be taking expert testimony on these days – but only on the general topic areas listed for each day. Though the general areas of topics will stay the same, the bullet points underneath each topic are likely to grow as committee members submit ideas.

If you have subject-matter expertise and would like to testify on any of these topics, please contact Emily Walker in my office at 573.751.2412.  

October 15th, 1:00 pm—Medicaid Fraud, Services Covered

  • Qui Tam
  • Medicaid Malpractice Reinsurance
  • Mental Health Services
  • Chiropractic
  • Other Services

October 29th, 1:00 p.m. – Delivery Models and Managed Care Bidding

  • Fee-for-service
  • ASOs
  • ACOs
  • HMOs and PPOs
  • Health Care Homes

October 30th, 8:00 a.m. – “Skin in the Game”

  • Cost Sharing
  • Debit Cards
  • HDHP w/ HSA

November 5th, 1:00 p.m. – ABD and Other Higher Cost Recipients

  • Aged, Blind, Disabled
  • Frequent Fliers

November 6th, 8:00 – Eligibility in Different Categoricals

  • Parents
  • Healthy Childless Adults
  • Medically Frail
  • Children
  • Pregnant Women
  • Women with Cancer
  • Ticket-to-Work

November 19th, 1:00 – Conclusions

Missouri Version of the Iowa Option

I’ve attached a PDF of mock legislation which would implement a Missouri version of the Iowa Option, the Medicaid reform recently enacted in Iowa. As with the mock bills modeled after Arkansas, the Patients Choice Act, and the Healthy Indiana Program this mock legislation is not my proposal for Medicaid transformation in Missouri – and does not have my endorsement. Instead, it is just another example of outside-the-box thinking which, if enacted, would bring market forces into Missouri’s Medicaid program.

Iowa – The Iowa Option in Mo Statute

Missouri Version of the Healthy Indiana Program

I’ve attached a PDF of mock legislation which would implement a Missouri version of the Healthy Indiana Program, a Medicaid reform enacted in Indiana in 2007 under former Indiana Gov. Mitch Daniels.

Like Paul Ryan’s proposed Patients’ Choice Act, the Healthy Indiana Program provided for premium assistance for previously uninsured Indians who earned up to 200 percent of the federal poverty level. Like Ryan’s bill, Mitch Daniels’ Healthy Indiana Program is just one of many conservative proposals over the past 25 years to bring market forces to the Medicaid program – and to do so at the same time that they increase effective eligibility rates for the working poor. The Medicaid transformation proposal I sponsored last session attempted to use the same market forces to bring down the costs of health care for all Missourians.

The Obama administration recently extended Indiana’s waiver to continue running HIP. Eligibility, however, will be reduced to 100 percent of the federal poverty level, and Indianans on the program between 100 and 200 percent of the federal poverty level will be informed of the opportunity to enroll in a subsidized exchange plan. (Indiana has an exchange being run by the federal government just as Missouri does.)

As with the mock bills modeled after Arkansas and the Patients Choice Act, this mock legislation is not my proposal for Medicaid transformation in Missouri – and does not have my endorsement. Instead, it is just another example of outside-the-box thinking which, if enacted, would bring market forces into Missouri’s Medicaid program.

Indiana – Healthy Indiana Plan in Mo Statute

Missouri Version of Paul Ryan’s Patients Choice Act

I’ve attached a PDF of mock legislation which would implement a Missouri version of Rep. Paul Ryan’s Patients Choice Act of 2009, which was presented as the Republican alternative to ObamaCare at the time it was being debated in Congress. The Senate champion of the measure was Oklahoma Sen. Tom Coburn.

The Patients Choice Act would have essentially increased Medicaid eligibility nationwide for families up to 200 percent of the federal poverty level. But it would have done so through tax credits and by providing these working poor families with debit cards through which they could use to buy their own private insurance. Ryan’s bill is just one of many conservative proposals over the past 25 years to bring market forces to the Medicaid program. The Medicaid proposal I sponsored last year included a similar approach – turning Medicaid recipients into participants by empowering them to choose their own health insurance plan in a truly competitive system which rewarded them for making affordable choices, and by providing each with a pre-paid debit card to use for co-pays in order to get them thinking about the costs of services just as every Missourian who pays the full freight for their health care does.

As with the mock bill modeled after Arkansas which I posted last week, this mock legislation is not my proposal for Medicaid transformation in Missouri – and does not have my endorsement. Instead, it is just another example of outside-the-box thinking which, if enacted, would bring market forces into Missouri’s Medicaid program.

Missouri Version of Paul Ryan’s Patients Choice Act

Interim Committee on Medicaid Transformation Hearing Information for September 26

September 26, 2013

House Hearing Room #1 or #3 (depending upon availability)

1:00 p.m. until testimony concludes or 5:00 p.m. at the latest


  • What’s a waiver and how can we qualify for one?
  • The Arkansas Model – Rep. Noel Torpey
  • The Iowa Option – Rep. Noel Torpey
  • The Healthy Indiana Program – Rep. Jay Barnes
  • Paul Ryan’s Patients Choice Act – Rep. Jay Barnes

Further details to follow.  

Troubling Social Promotion Policies in St. Louis Public Schools

State Auditor Tom Schweich released a report yesterday on St. Louis Public Schools. Two points worthy of quick note:

  • The district violated state law by regularly promoting students to the next grade level even if they can’t read. The P-D explains:

But what troubled Schweich the most is the district’s practice of moving children to the next grade level even though their reading skills are sub par. More than 2,000 students tested at the “below basic” level — the lowest performance category — in the 2011 and 2012 reading section of the Missouri Assessment Program. Yet just 158 and 128 students were held back those years, respectively. Holding back each child who is behind in reading, as mandated by state law, would be too costly, administrators told Schweich’s staff.

“I don’t know what the priorities are as far as finances go, but at least in our view students who can’t read should be the highest financial priority,” Schweich said in downtown St. Louis.

Rick Sullivan, president of the district’s state-imposed Special Administrative Board, said the retention issue was a tough problem to solve.

“The number of students who would be retained would be staggering,” he said. “But that’s the question people have asked for years and years.”

Social promotion might help the school’s finances in the short-run, but doesn’t help the kids – or the district – in the long-run. 

  • Schweich found the district did an inadequate job of detecting or deterring cheating on standardized tests. There’s good news here though. In 2012, I sponsored legislation to require the Department of Elementary and Secondary Education to buy software to detect and deter cheating on standardized tests statewide. That bill did not pass, but after continued discussions with DESE, the department requested funds in this year’s budget to buy the software. Because it just passed in this year’s budget, the software wasn’t available for use during the testing periods covered by Auditor Schweich’s report. However, it should be available everywhere in the state for this year’s standardized tests. 

How Did Unions Get Exempt from Ethics Requirements?

The unmatched Dave Drebes reports this morning that unions somehow exempted their members from Missouri’s ethics laws. Section 105.475.2 provides that lobbyist reporting rules “shall not apply to any member of a union who is acting in either an employment capacity or contractual capacity in association with the union, except if such person’s employment or contractual capacity is as a lobbyist for the union.”

To be clear, I don’t know of any high-frequency union lobbyists who fail to comply with the lobbying statutes anyway. Even if they’re exempt, they register anyway. But it’s more than a little ridiculous that this special interest exception exists.  

Can’t Make This Stuff Up – Lib Defends Lottery Tickets for Welfare Recipients

You can’t make this stuff up. The legislature passed a bill this year to prohibit the use of welfare for strip clubs, liquor, or gambling. Glenn Koenen of the Missouri Association for Social Welfare went on the Charlie Brennan show to argue that welfare (TANF) recipients should be allowed to use their welfare to buy lottery tickets.

Seriously? Koenen argues that since TANF doesn’t provide much money, so “they can’t be wasting their money” if they’re making less than $300 a month.” Ummm, lottery tickets are a complete waste of money. Why would any advocate for the poor want welfare recipients spending their money on scratch-offs that give them a 15-second high – and just pours their money down the drain. If a person has enough money to buy a lottery ticket, they shouldn’t be on welfare.

Koenen makes me think we didn’t go far enough. Perhaps we should pass a law requiring any person who wins the lottery while on any welfare program to re-imburse the state of Missouri for all prior benefits received – times two?

One point raised in the Brennan interview, however, might deserve a second look. The bill they’re discussing (1) has a potential “void for vagueness” problem for items outside of stip clubs, liquor, and gambling that needs to be fixed, and (2) likely needs a little better clarification on the responsibilities of store clerks.   

Peggy Noonan and Bill McClellan on Work

Two good columns today on an undercurrent of fear that the American dream is slipping away.

Noonan writes on the value of work, and its integral place in the American character. She writes that concerns over work and unemployment numbers are about more than some Gradgrindian obsession with statistics and fancy charts. Work has a spiritual component:

A job isn’t only a means to a paycheck, it’s more. “To work is the pray,” the old priests used to say. God made us as many things, including as workers. When you work you serve and take part. To work is to be integrated into the daily life of the nation. There is pride and satisfaction in doing work well, in working with others and learning a discipline or a craft or an art. To work is to grow and to find out who you are.

In return for performing your duties, whatever they are, you receive money that you can use freely and in accordance with your highest desire. A job allows you the satisfaction of supporting yourself or your family, or starting a family. Work allows you to renew your life, which is part of the renewing of civilization.

Work gives us purpose, stability, integration, shared mission. And so to be unable to work—unable to find or hold a job—is a kind of catastrophe for a human being.

The Committee on Government Oversight and Accountability talked about this when we convinced the Department of Social Services to cancel a contract it had which would have encouraged Missourians to apply for disability who might otherwise be able to work. A life without work – or a sense of mission – is not a full life.

Bill McClellan gives a particular example from St. Louis in his own column today. McClellan tells the story of Tom Nutter, a 67 year-old attorney in St. Louis, who, despite experience, education, and a willingness to work, can’t find a suitable job – and has moved into a small house just about a mile from where he grew up – where he benefitted from a stay-at-home mother because his non-college educated father was able to support a family of six kids and put them through private school.

In his typical style, McClellan just tells his story.  Noonan asks for hope – real hope this time:

What is needed now is a political leader on fire about all the possibilities, not one who tries to sound optimistic because polls show optimism is popular but someone with real passion about the idea of new businesses, new inventions, growth, productivity, breakthroughs and jobs, jobs, jobs. Someone in love with the romance of the marketplace. We’ve lost that feeling among our political leaders, who mostly walk around looking like they have headaches. But American genius is still there, in our garages. It’s been there since before Ben Franklin and the key and the kite and the bolt of lightning.

I’m with Peggy. The American people don’t have “hope” that bigger government is going to swoop in and save the day. And, to be clear, neither do they believe that government should just let the Wall Street financiers continue to wreak havoc on the economy with no restraint and no consequence. Noonan’s is a hope based on actual productivity – the building of real businesses.

There are a number of different policies to encourage this: we could start by dramatically reducing our federal corporate income tax rate – which is the highest in the entire developed world. It would continue with tax reform led by Rep. Dave Camp (R-Mich) which removes special interest tax breaks from our tax code and reduces the tax burden on small businesses. There are other, of course, but those will wait for another day…