Category Archives: Health Care

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

The Arkansas Model

Attached is draft legislation of “The Arkansas Model” incorporated into Missouri statutes. This Medicaid reform model will be discussed at the hearing of the House Interim Committee on Medicaid Transformation on September 26 at 1:00 p.m.

I will post more draft legislation as it becomes available for distribution.

The Arkansas Model 

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.  

Medicaid Committee Testimony

The first of two House interim committees on Medicaid is holding its first hearing this morning. Acting DSS Director Brian Kincaid is testifying today on the history and current structure of Missouri’s Medicaid program.


2013 Session Legislative Recap

The last two weeks of session are hectic every year. This year, however, seemed the most hectic yet in my three years of service. As bills pass across the rotunda from chamber to chamber, sometimes it’s difficult to keep track of everything that the Senate is doing to send bills to the governor’s desk. With a weekend of much-needed yard work behind me, I thought I’d recap the accomplishments from this session in which I played a role. 

  1. MSP Re-Development and Capitol Maintenance –The budget included $38 million in the budget for the construction of a new state office building on the grounds of the old Missouri State Penitentiary and $50 million for long overdue maintenance in the state capitol. The $38 million investment at MSP will kick-start further redevelopment by ensuring a critical mass of people who work there. The $50 million for maintenance will ensure that our state capitol remains the treasure it is today. Just as a homeowner must invest in repairs and upkeep, so too must state government ensure that our buildings do not fall into disrepair. 
  2. Raises for State Employees – The budget included a $500 raise for all state employees. We still rank 50 out of 50 and $500 is not enough to get us out of the basement. But, it’s the second year in a row in which state employees have received a raise after six consecutive years without one. Moving in the right direction is a win.
  3. Education Reform for Struggling School Districts Senate Bill 125, which I handled in the House, will put St. Louis schools on equal footing with other districts in the state by allowing it to terminate teachers found incompetent. It will also allow the State Board of Education to intervene immediately in an unaccredited school district rather than waiting two years as it has to under current law. This will help ensure that students in struggling districts get appropriate help from the State Board as soon as possible. While this bill was not as transformative as we initially attempted, it is the most substantive education bill to pass since the re-write of the foundation formula in 2005.
  4. Medicaid Transformation House Bill 986 and Senate Bill 127 combined do four things relating to Medicaid: (1) extend Ticket-to-Work, a program which helps Missourians with disabilities keep health insurance while employed, (2) place foster children on equal setting with children of traditional families for health insurance, (3) streamline Medicaid eligibility and require annual re-determinations through electronic searches to root out waste, fraud, and abuse, and (4) allow the creation of a Joint Interim Committee on Medicaid Transformation for a group of senators and representatives to study how we might transform Missouri Medicaid into the most market-based public health care system in the entire history of the federal program.
  5. Saving First Steps – After the House and Senate passed a balanced budget using Gov. Nixon’s original recommendation to eliminate the circuit breaker tax credit, Gov. Nixon vetoed the circuit breaker legislation. As a result, First Steps and federally qualified health centers could not receive funding unless the legislature passed a bill to create the Senior Services Protection Fund. In order to save First Steps and FQHCs, House Bill 986 created the Senior Services Protection Fund and was sent to the Gov. Nixon’s desk Friday afternoon.
  6. Strengthening Missouri’s Law on Rape – Missouri’s law on rape has a loophole which prevents a charge of rape against a perpetrator who commits the crime against a victim who has become incapacitated as a result of anything other than the perpetrator’s conduct. The defendants in the infamous Steubenville case from Ohio unsuccessfully used a similar loophole in Ohio law as their defense. I sponsored legislation this year to close this loophole, attached it as an amendment to at least three separate bills, and I’m pleased to report it’s on the governor’s desk as an amendment on House Bill 301, sponsored by Rep. Kevin Engler.  
  7. Tax Credit Reform – The ‘Buck Stops Here Tax Credit Reform Act of 2013,’ aka “Missouri Works,” will consolidate several economic development programs into one which provides DED with much more flexibility to say no. The goal: more Monsantos and less Mamteks. We want DED to be able to weed out bad projects. This legislation was passed via amendment to House Bill 184, sponsored by Rep. Stanley Cox.
  8. Veteran’s Courts – Veterans suffering post-traumatic stress disorder deserve our help. Senate Bill 118, sponsored by Sen. Will Kraus takes veteran’s courts statewide, will help ensure that veterans with PTSD in legal trouble get the help they need to turn their lives around.  We know that veterans are capable of being productive members of society. Getting them the right kind of medical treatment will put them back on the path to success. SB 118 is very similar to my legislation and to legislation sponsored by Rep. Sheila Solon, who deserves credit for her work on this issue as well.

House Perfects Medicaid Transformation Related Bill

The Missouri House perfected HB 986, a Medicaid transformation-related bill, by voice vote this afternoon. HB 986 would:

  1. Create a Joint Interim Committee on Medicaid Transformation to facilitate bicameral discussion of what I believe is the most important issue facing our state over the interim.
  2. Extend the Ticket-to-Work program by six years. This program encourages disabled Missourians on welfare to obtain and keep employment. 
  3. Increase eligibility for foster children to age 26 to match the insurance coverage available to other children in private insurance marketplaces. 
  4. Streamline the income eligibility process by moving from AFDC with income set-asides to MAGI with an automatic five percent set-aside. This measure is a little like what federal tax reform would look like if Washington would get serious. We take a complicated formula full of exceptions, exemptions, and loopholes and replace with a simple one that’s easy to explain and apply. 
Obviously, I’m disappointed at not having a comprehensive bill that will get across the finish line. However, it’s my great hope at this point that we can work together with leaders from the Senate over the interim to re-make Missouri’s Medicaid system into the most market-based system in the entire history of the federal program. 

Medicaid Transformation Not Brinks Truck Economics

This bill proposed to build a Medicaid mansion on a crumbling foundation. Our current Medicaid system is broken. In most geographical regions of the state, Medicaid works on a fee-for-service basis with no incentives for affordability for anyone. Worse, study after study has shown that Medicaid leads to worse results for recipients than for persons with private insurance coverage – even controlling for income.

We have a Medicaid foundation that’s bad for both Missouri taxpayers and recipients. The gentlemen’s amendment (to expand Medicaid on this crumbling foundation) does nothing to fix this problem. There is a better way.

There’s a way we can transform Medicaid to save money and improve health outcomes. We can turn recipients into participants in their own health care by introducing price competition for the first time in the history of the federal Medicaid program.

Mr. Speaker, let’s transform Missouri’s Medicaid system into the most market-based system in the history of Medicaid. We can build a system through HB 700 which would save Missouri taxpayers at least $742 million over eight years and perhaps over a billion dollars.

Mr. Speaker, I urge the body to reject the Gentleman’s attempt to build a mansion on this crumbling foundation. Let’s pour a new foundation, a stronger foundation, a foundation that is fiscally-sustainable and uses market forces to improve results.  

QA on Medicaid Transformation Legislation

Explain the bill in one paragraph. This proposal would force Governor Nixon to request a waiver out of ObamaCare. It would eliminate Medicaid as the world has known it and replace it with the most free market public health system in the entire country. For the first time in history, Medicaid recipients would be empowered to make their own health care choices and incentivized to choose affordable health insurance plans by the injection of price competition into Medicaid. 

Explain the price competition. When a recipient signs up for Medicaid, they will be presented with a list of available health insurance plans with a list of corresponding prices. If the recipient picks the lowest case plan, they will be allowed to keep a portion of the difference between that plan and the highest cost plan offered. In other words, recipients will be given the same price incentives that other Missourians face every time they decide which health insurance plan will work best for them. Price will matter for the first time in the history of our federal Medicaid program.

Has any state ever done this before? Not to my knowledge. Indiana introduced the concept of high-deductible health plans in 2008 when it created the Healthy Indiana Plan, but it did not introduce direct price competition on premiums for managed care plans in Medicaid.

If no state has ever done it before, how do we know it’s possible? There is no federal law or rule which directly prohibits incentive payments based on choosing an affordable plan. There is precedent for cash payments to Medicaid recipients as incentive to engage in healthy activities – and thereby bring down costs. These waivers have been granted in Florida and New York. Because there is no federal law or rule directly prohibiting the injection of price competition into Medicaid, the federal government has the legal authority to grant a waiver. Whether it does or not depends on whether the Obama administration is willing to put ideology aside and let Missouri reject the one-size-fits-all central-planning ObamaCare model. 

What happens if we don’t get the Market-Based Medicaid waiver? If the federal government refuses to allow true price competition into Medicaid for the first time in history, then this legislation has no effect. It’s an all-or-nothing proposition.

Why not just scrap Medicaid altogether? The current situation presents a unique opportunity to craft the most market-based Medicaid program in the entire country. In the Cold War, we had a great battle between an economic system based on decentralized decision-making that relied on the wisdom of ordinary people to make economic decisions versus one that was centrally-planned with so-called experts making all pricing decisions. As Ronald Reagan would put it, “We won. They lost.” Unfortunately, central planning lives on in many ways in American governance, including through state Medicaid programs with prices set by government bureaucrats. We know from history that central planning does not work – and yet it persists in Medicaid. We also know that Medicaid is here to stay. The program has been in existence for 47 years with no serious effort ever made to repeal it. No matter what Missouri does on the ObamaCare expansion of this broken system, Medicaid will march on – consuming more and more of the state and federal budget. This legislation sets up another great test, with Missouri leading the way for a free market model that can save billions and perhaps trillions of dollars across the nation by introducing price competition to Medicaid for the first time in the 47 year history of the program.  

What will this do to the federal deficit? According to the Heritage Foundation, the federal government spent $3.6 trillion in 2012. If Market-Based Medicaid becomes law, the federal share for Missouri would be increased by $1.2 billion in 2014 – a total which represents 1 / 3,000 share or 0.0003 percent of total federal spending. Further, according to Kaiser, the state of New York’s Medicaid program cost $52.1 billion and California’s cost $42.1 billion in 2010. Total Medicaid spending in 2010, according to Kaiser, was $389 billion. This bill could serve as a catalyst to save money by proving how injecting real free market measures into Medicaid could save billions of dollars if adopted nationwide.  Just as businesses are willing to invest portions of the budgets in research and development of products and systems which can save their own company and their consumers money, so too should conservatives be willing to force the Obama administration to invest in Market-Based Medicaid with Missouri as the laboratory of democracy to prove, once again, that decentralized decision-making beats central planning every time.

What happens if the federal government breaks its promise? There’s an automatic trigger in the bill which rescinds all eligibility increases if the federal government breaks its funding promises.

How can Missouri taxpayers afford this? The legislation has a tremendous positive fiscal note for Missouri taxpayers. In its first eight years, the bill would save Missouri taxpayers at least $741.9 billion. In 2021, the first year Missouri would be responsible for its full 10 percent share, the bill has a positive fiscal note of $83.5 million. If we assume savings of just 1.5 percent from high-deductible health plans and a mere three percent for the introduction of price competition for the first time in the history of Medicaid, the bill would save Missouri taxpayers approximately $927.8 million over the first eight years and $109.1 million in 2021. In addition, a provision increasing cost-sharing for pharmaceuticals and specialist doctors visits has not been scored yet.

What does this do to the total number of Missourians eligible for Medicaid? Under this proposal, the number of Missourians eligible for Medicaid will decrease.

Can Missouri get an enhanced match rate at 100 percent of the federal poverty level? In December, eleven Republican governors wrote a letter to HHS Secretary Kathleen Sebelius requesting clarification on whether the enhanced federal match rate would be available at 100 FPL. Sebelius said no. That decision was a political decision, however, not a legal decision. As explained by Charles Miller, senior counsel at Covington & Burling, a mega-law firm in Washington D.C., the NFIB v. Sebelius case gave the Obama administration the legal authority it needs to deviate from the 138 percent requirement. Miller told the Washington Post:

“The court said . . . we’re not allowing you to enforce this so-called mandate,” Miller said. “So what is a mandate when you can’t enforce it? I think it’s not un-sensible to say that a mandate then becomes an option. . . . And in that context does it have to be all-or-nothing? Neither the Supreme Court nor the original statute addressed that point.”

Even assuming the Obama administration refuses to drop its ideological one-size-fits-all edict on this part of the law, there are other things states can do to require recipients to share costs when they make more than 100 percent of the federal poverty level. A new proposed federal regulation, for example, would allow states to require recipients to pay 50 percent of their costs from the first day of hospitalization. Existing federal rules allow states to require recipients between 100 and 138 percent of the federal poverty level to pay up to 10 percent of the cost of a service through co-payments and up to 5 percent of total family income. The subsidies available through a federal health insurance exchange for these populations would be less than the cost-sharing allowed by federal law. By adopting all cost-sharing requirements allowed in existing federal law, a state can make Medicaid a less affordable option for health insurance coverage than a private plan through a federally-facilitated exchange which would require the individual to choose their own plan and pay monthly premiums. 

Why reduce Medicaid eligibility for some groups? Won’t this deny them access to healthcare? The bill reduces eligibility for groups above 100 percent of the federal poverty level because, by definition, people above the poverty level do not live in poverty. They should be expected to make personally responsible decisions to purchase their own health insurance plans. The reductions in eligibility are contingent upon the existence and functioning of a federal health insurance exchange which is offering subsidies for insurance coverage for the populations with reduced eligibility. Under these subsides, for example, a single mother who makes $20,628 per year (133 percent of the federal poverty level) will only have to pay two percent of her income, or $34.38 per month on premiums for an insurance plan in the exchange that covers her family. See this memo from Kaiser re: exchange subsidies. Reducing eligibility for Medicaid for these populations will result in better care as these Missourians choose their own private health insurance plans.

Why not just do reform only? First, because Governor Nixon is highly unlikely to sign a reform only bill, and would not have anything to offer the Obama administration when he demands the ObamaCare Medicaid opt-out. Second, because the powerful provider lobbies in our state hold enough sway in our state capitol that they could – and would – kill any effort at a reform-only bill. Third, reform-only does not solve the serious problem faced by rural hospitals in Missouri losing disproportionate share payments from the federal government to reduce the costs of charity care which federal law (EMTALA) requires them to provide. (Yes, this is a problem caused by the Obama administration and not us. But the argument that “because someone else did it, it’s not our responsibility to help” is like saying that we should ignore a person bleeding in the street after getting mugged because, well, “we didn’t do it, it’s not our responsibility to help clean up that mess.”) In order for real reform with price competition to ever become law, some increases in eligibility are necessary.

Why a high-deductible health plan? The high-deductible health plan is modeled after the Healthy Indiana Plan, a successful program started by Indians Gov. Mitch Daniels. Recipients are incentivized not to waste health care dollars because accessing care requires them to use funds in the Health Savings Accounts attached to their high-deductible plans.

What about the elderly, persons with disabilities, and those with chronic conditions? This bill does not impact elderly Missourians on Medicaid. Persons with disability and chronic conditions are carved out of managed-care and given “health care homes,” a care-coordination model started in Missouri by former Gov. Matt Blunt which has proven to save money.

Why is pharmacy carved-out of managed care? The Department of Social Services can manage pharmacy benefits through an ASO cheaper than managed care companies can because DSS gets pharmacy discounts for buying in bulk. 

Why do the benefits of the transformed Medicaid plans match the benefits to be offered by plans in a federally-facilitated exchange? The benefits match in an effort to remove disincentives that Medicaid recipients currently have to taking a better job or working more hours. Unfortunately, the welfare state is set up so that it is morally repugnant but economically rationale for some welfare recipients to choose not to increase their income when they have the opportunity. We match the incentives so that a recipient on the verge of “churning-out” of Medicaid does not have the disincentive of losing health insurance coverage. Instead, their Medicaid plan will be rolled-over into an exchange plan with the recipient now responsible for premium payments.

Why provide for commercial rates of reimbursement to providers? Medicaid critics from both the right and the left have long decried that measly reimbursement rates for providers reduce the ability of recipients to actually receive care in rural areas because so few providers participate in Medicaid. In order to have a program which actually works for those who need it, provider reimbursement rates have to be competitive. This legislation presumes commercial rates of reimbursement which should increase the willingness of doctors to participate.

How will this cut down on fraud? Recipients will be given an electronic card which they will have to use when accessing health care services. These cards will allow DSS to track spending in real-time. Just as credit card companies are able to shut off a customer’s credit card after unusual activity, so too should DSS be able to identify unusual patterns of activity to prevent fraud. Perhaps even more importantly, managed care companies have incentives to reduce fraud and will likely do a better job of it. 

What evidence is there that private plans produce better health outcomes for recipients than centrally-planned Medicaid?

Here are just a few of many studies on the issue:

–      Children with asthma on Medicaid more likely to endure long hospital stays with “significantly poorer outpatient care.” Quality of Hospital Care of Children with Asthma: Medicaid Versus Privately Insured PatientsJ. of HC for the Poor and Underserved, Vol. 12, No. 2 (2001), pp. 192–207. 

–      Medicaid recipients diagnosed later with cancer, less likely to receive cancer-related surgery, and have higher mortality rates. The Relation Between Health Insurance Coverage and Clinical Outcomes Among Women with Breast Cancer,”New Eng. Journ. of Medicine, July 29, 1993, pp. 326–331; Effects of Health Insurance and Race on Colorectal Cancer Treatments and Outcomes, American Journal of Public Health, 90 (2000), pp. 1746–1754; Disparities in Cancer Diagnosis and SurvivalCancer, Vol. 91 (2001), pp. 178–188; Cancer Survival in Kentucky and Health Insurance CoverageArchives of Internal Medicine, Vol. 163 (2003), pp. 2135–2144 

–      Higher mortality rates for non-cancer patients for heart attack, stroke, and pneumonia – even adjusting for age, gender, income, other illnesses, and severity. Insurance Status and Hospital Care for Myocardial Infarction, Stroke, and PneumoniaJournal of Hospital Medicine, Vol. 5, No. 8 (2010), pp. 452–459 

How will this transformed system differ from managed care in the existing I-70 corridor? In the current managed care corridor, price is centrally-planned and set by the Department of Social Services. Bidders compete on the basis of the breadth of their network and services provided. In the transformed system, bidders will be required to compete on price, with the lowest cost conforming bid guaranteed acceptance. Bidders will be incentivized to make their plans as affordable as possible for Missouri taxpayers because they will want to win the guaranteed slot. In addition, they will compete for market-share on the basis of price from recipients who will be told that they will be rewarded for making affordable health care choices for the first time in the history of the federal Medicaid program.