Category Archives: Health Care

Injecting Market Forces Into Missouri’s Health Care Welfare System

Imagine going to a grocery store where there are no prices on the food and the government has told you that it will pay for whatever you or the clerk think you need. How much restraint would you exercise? How much restraint would you expect the clerk to exercise? Most of us like to think that we’d do the right thing, and I believe most people would. But, as Madison pointed out, “If men were angels, no government would be necessary.” 

Incredibly, in many parts of our state (and nation), Medicaid operates on a fee-for-service basis similar in concept to the absurd thought experiment outlined above. A Medicaid recipient who has no money presents at a health care provider for services. The recipient pays no co-pay – or only a nominal amount. And at no point does price ever matter.  And then they send the bill to you, the taxpayer. It’s all gas, no brakes.

By contrast, in the I-70 corridor, recipients are covered by managed care plans which operate similarly to private health insurance plans. They inject a level of oversight into Medicaid transactions to protect taxpayers from wasteful and, in some cases, fraudulent health care claims. The I-70 corridor managed care plans have proven to be more affordable to Missouri taxpayers without sacrificing quality for recipients.

But Medicaid-managed care needs reform as well. Under the current system, managed care companies do not compete directly on price. Instead, the Department of Social Services names its price and asks the managed care companies to match it. Though DSS engages a top-flight actuarial firm to set its price, the more efficient approach would be to allow free market forces to establish the price, versus the decision of a single firm. If the price is too low, managed care companies will let DSS know and no bids will be received. If, however, the price is too high, no managed care company is going to tell DSS they’ve priced the bid wrong. Instead, they’ll be happy to pocket higher profits off of Missouri taxpayers.

Nor are recipients in the current managed care corridor given financial incentives to use taxpayer resources wisely. Because recipients have only limited financial resources, there are no penalties for misuse of the ER. Likewise, there are no bonuses for healthy or appropriate behaviors.

For the last two years, I’ve worked with many elected officials, health care providers, and ordinary citizens to develop a better plan for Missouri’s Medicaid system. House Bill 1901, sponsored by Rep. Noel Torpey, is one result of that work, and the House Committee on Government Oversight and Accountability has spent three weeks hearing the bill. To inject market forces into Missouri’s Medicaid system, House Bill 1901 would:

  • Eliminate fee-for-service and expand managed care statewide;
  • Require actual price competition in the bidding process for managed care companies;
  • Foster competition by allowing networks of health care providers to form Accountable Care Organizations to compete with more traditional managed care companies;
  • Turn recipients into participants by empowering them to choose their own health plan based on cost and services;
  • Encourage participants to choose low-cost plans by offering financial incentives for them to select the most affordable option. Just as you and I have financial incentives to choose more affordable health insurance plans, so should Medicaid participants.
  • Provide participants with a state-funded cost-sharing card that the participant must use each time they receive a health care service. To encourage healthy behaviors, if the participants use care efficiently and go to preventive care appointments, they should be rewarded. If they misuse the ER, they should be penalized.

House Bill 1901 is similar to previous proposals by stalwart conservatives like former Gov. Matt Blunt, Texas Gov. Rick Perry, and former Indiana Gov. Mitch Daniels – each of whom proposed increasing Medicaid eligibility far beyond what is contemplated in HB 1901. If passed, this market-based Medicaid plan could serve as a conservative model for the rest of the country on how to inject market forces into the system to save taxpayer money and improve the quality of care.

If we could turn the clock back to 2007, I believe HB 1901 would be considered a leading conservative alternative to ObamaCare. It extends health care coverage to the working poor who otherwise can’t  afford private health insurance. This can save money over the long-term.  I believe ideas still matter, regardless of political labels people try to affix to them, and I’m hopeful that HB 1901’s conservative plan for Missouri Medicaid will be passed into law.

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.

Request to Allow Missouri Consumers the Freedom to Keep the Health Plan

This morning I sent the following letter to Director John Huff at the Department of Insurance requesting the Department to reverse course and allow Missouri consumers the freedom to renew their existing health plans free from Obamacare mandates:

Dear Director Huff:

In the past few weeks, millions of Americans have suffered cancellation of their existing health insurance policies as a result of the Affordable Care Act. In many states, the impact of these new regulations was mitigated by state departments of insurance which allowed health insurance consumers to renew their policies early – thus giving those policies “grandfather” status for approximately another year and avoiding cancellations. Unfortunately, Missourians did not have that option. In fact, according to the New York Times, Missouri was one of just seven states that refused to allow early renewals to avoid the blunt impact of Affordable Care Act mandates.[1] 

This was the result of Bulletin 13-01, a directive of the Department which warned health insurers that the Department would interpret three statutes to prohibit early renewals – even at the consumer’s option. To my knowledge, these statutes had never been interpreted in such a manner. While the Department’s position is a colorable interpretation, it is at least equally reasonable for the Department to conclude that renewals at a consumer’s option are legal. In addition, when interpreting ambiguous statutes, I believe the best policy position for the Department is to choose the path which permits the greatest amount of consumer freedom.

I write today in light of the spate of recent cancellations around the country and ask you to reconsider, rescind, and replace Bulletin 13-01 with a new Bulletin reversing the Department’s interpretation of the relevant statutes. Doing so quickly would give as many Missourians as possible the opportunity to renew their policies before their cancellation at the end of the year – mitigating some of the negative impacts of the Affordable Care Act. I will also be pre-filing legislation to (1) clarify the meaning of “renewal” in these statutes, and (2) require the Department to allow consumers to renew existing plans. I look forward to hearing your response regarding the request to immediately rescind Bulletin 13-01.


Rep. Jay Barnes

c.c. The Honorable Jay Nixon

[1] The other states were Massachusetts, New York, Rhode Island, Washington, Oregon, and California. States That Had Already Been Allowing Policyholders to Renew Their Plans Before President Obama Made His Announcement, NY Times, published November 20, 2013 at

I also sent the following press release to the Associated Press and a few other outlets. 


Rep. Jay Barnes Requests Dept. of Insurance Reverse Decision Prohibiting Missouri Consumers from Renewing Health Plans Early to Avoid ACA Insurance Cancellations

Jefferson City – State Representative Jay Barnes (R-Jefferson City) has requested that the Missouri Department of Insurance reverse an earlier decision which made it impossible for Missourians to avoid Affordable Care Act insurance cancellations. Barnes specifically asks for the replacement of Bulletin 13-01, a directive sent by the Department in early June warning insurance companies that they could not renew policies early, even at the option of the consumer, to avoid ACA-mandated cancellations.

“We have a duty to protect Missourians the best we can from the ill effects of Obamacare,” said Barnes. “Rescinding Bulletin 13-01 quickly would give as many Missourians as possible the freedom to renew their existing insurance policies. Reversing course is the right thing – and the smart thing – for Governor Nixon and the Department of Insurance to do.” 

Important Source Documents:

By the time I returned to my office I learned that Gov. Nixon announced, via press release, that insurance companies would be allowed to continue cancelled plans. My thoughts: as stated in my press release above, this is the right thing, and the smart thing to do for Missouri consumers suffering policy cancellations due to ACA-mandates. I’m pleased with the quick turnaround – and I still believe Bulletin 13-01 should be withdrawn in its entirety. 

Rep. Sue Allen – Medicaid Managed Care Proposals

Rep. Sue Allen will present legislative language on Medicaid managed care Wednesday morning before the House Interim Committee on Government Oversight and Accountability. Her proposals can be found in HB 925 and HB 926 from 2013.

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

Managed Care and Cost-Sharing Language

I’ve uploaded a PDF of proposed statutory changes to Medicaid which I will present at next weeks hearings of the House Interim Committee on Medicaid Transformation.

As with previous presentations, the inclusion of this proposal does not mean I or the committee will necessarily be endorsing it for passage by the General Assembly. What it does mean is that it contains key concepts which I believe should be discussed for Medicaid Transformation.

Managed Care and Cost Sharing

In addition to this proposal, the Committee will also receive presentations by Rep. Keith Frederick and Rep. Sue Allen, who will be presenting versions of bills they filed last year. I will post those bills tomorrow. 

Switching Next Week’s Hearings

The Interim Committee on Medicaid Transformation is reversing the order of topics to be discussed next week. The following is the schedule we will follow: 

October 29th, 1:00 p.m. – “Skin in the Game”

  • Cost Sharing
  • Debit Cards
  • HDHP w/ HSAs

October 30th, 8:00 a.m. – Delivery Models and Managed Care Bidding

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

Hearing on Services Covered

The House Interim Committee on Medicaid Transformation will take testimony tomorrow on services covered by Medicaid and Medicaid fraud. I’ve attached a PDF of a list of potential services covered in the form of a section of a potential state statute.

MoHealthNet Services Covered

The following witnesses are also expected to testify: 

·         Joel Ferber,  Legal Services– Medicaid Services overview

·         Dr. Michael Bleich, BJC Goldfrab School of Nursing

·         Brent McGinty, Coalition of Committee Mental Health Centers—substance abuse 

·         Jack Hollister, MO Psychological Association 

·         Dan Body, Regional VP for Behavioral Health for SSM Healthcare 

·         Brent Gilstrap, President of MO Mental Health Counselors Association 

·         Sherriff’s Association on topic of Mental Health coverage

·         Jane Moore, MO Hospice and Palliative Care Association 

·         Lynne Barbour, DDS MO Dental Association

·         Dr. Gary Henley  Coalition for Dental Health

·         John Kopp, Deputy Director of Medicaid Fraud Control Unit, Mo. AG

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