Summer has been moving along quickly, and it's hard to believe that school is set to begin within the next two weeks for many of our kids. This time of year reminds me of our local County Fairs, and I really enjoyed attending the Phelps County Fair (while returning from a Budget Committee meeting in Jefferson City) last week to visit with a number of constituents from that area of the 142nd District.

Summer has been moving along quickly, and it's hard to believe that school is set to begin within the next two weeks for many of our kids.  This time of year reminds me of our local County Fairs, and I really enjoyed attending the Phelps County Fair (while returning from a Budget Committee meeting in Jefferson City) last week to visit with a number of constituents from that area of the 142nd District.  The Texas County Fair/Old Settlers Reunion begins this Thursday in Houston.  I hope you will join me in supporting our area's youth, as the fair/livestock auction represents the culmination of many months of hard work and planning on their part. 

Also on the short term calendar is the August 5th primary election.  While most counties in the 142nd District may only have one or two contested races; much will be decided in the way of ballot measures (Amendments - 1, 5, 7, 8, & 9) that will change our Missouri Constitution if approved.  For further information on what will be decided, you can refer to my previous Capitol Report, visit the Secretary of State's website or call my Capitol office and we will gladly provide further information.  I would encourage each of you to let your voice be heard, and to remind your family, friends, and coworkers to exercise their right.  You can rest assured that if you fail to voice your opinion through voting; someone else will gladly speak for you (us)!

I realize that this is a lengthy report, but it speaks to a rather complex subject which requires a lot of detail.  Should you have questions after reading through, please contact my office and we will do our best to accommodate.

Medicaid Expansion / Texas County Memorial Hospital (TCMH)-

Following the recent TCMH board meeting, the discussion which was published thereof, and the mis-information that has apparently been distributed to a number of employees (who have written me), it appears necessary to re-discuss/clarify this issue.  My office received an invitation from TCMH CEO Wes Murray to attend an upcoming board meeting (June/July/August) to discuss health care policy and its effect on our local hospital.   With Budget hearings and prior meeting commitments, I was unable to attend the June/July meetings.  After hearing the comments made at the recent meeting, I felt somewhat like a friend had maxed out their credit card, and was then blaming me because I should have approved an increase!

Neither I nor the Missouri Legislature played any part in the financial and administrative decisions that have caused the current hardships at TCMH, and this appears to be a cheap attempt to blame others for poor management/decisions. I oppose deficit spending and hidden tax increases. I oppose Medicaid expansion because it will make problems much worse, not better, for everyone -- including and especially our rural hospitals! I oppose making our health care quality worse. The claim being made is just one more part of the ObamaCare bait and switch scheme to make the taxpayers of Missouri responsible for bailing out Washington DC.  

To fully understand the situation, we should recap a series of events that have brought us to where we find ourselves today.

With the passage of the "Patient Protection & Affordable Care Act" (ACA) aka ObamaCare in 2010, one of the key elements involved shifting a large portion of those uninsured to Medicaid.  While many affectionately refer to this as the "Law of the Land," the notoriously long bill has since prompted over 20,000 pages of accompanying regulations, and has been changed 42 times (as of July 2014) through legislative, administrative, and court actions.  Many companies/industries (and even congress) have been exempted from participating/complying through executive orders, and you will recall the infamous supreme court decision in 2012 citing a "penalty" as unconstitutional, but upholding the Federal ability to tax.  Another key provision in the 2012 opinion dealt with the expansion of Medicaid across the country, in saying that the Federal Government cannot penalize states for not participating; thereby making Medicaid Expansion "voluntary" on a state-by-state basis.  The portion of ObamaCare that was set to eliminate the Disproportionate Share Hospital (DSH) payments remained unscathed in the court's opinion, which relates to the "reimbursement reductions" and declining revenue that has been a major topic of contention and discussion for many hospitals, in the revenue that they are no longer seeing.  While not directly applicable to this discussion, it should also be mentioned that as recently as last week two decisions were handed down at the appellate level (Halbig v. [Sebelius] Burwell; and King v. Burwell) that are centered on the original law as written, and whether subsidies for insurance coverage are applicable to the states (34) that have opted not to set up state exchanges (while 16 + D.C. have set up state exchanges).  Missouri is one of the 34 states that has chosen not to set up a "state" exchange, and has also not expanded Medicaid coverage to those below the 138% of the Federal Poverty Level (FPL).  While expanding Medicaid is considered a "voluntary" option, like virtually all other Federal mandates/regulations/programs, this is tied to Federal funds [carrot] that are promised in the event that Missouri would reach an agreement with the Feds concerning expanding Medicaid.

As a State Representative, there is a broad range of groups/constituents and for each proposed issue I do my best to know how each will be impacted.  I understand the confusion and frustration of the employees at TCMH and other hospitals across our state that have been told "Missouri's legislators are at fault; we have to expand Medicaid, or the hospital will close." or "Passing Medicaid expansion will help our economy."  The same individuals peddling this nonsense are attempting to pass the blame for poor fiscal management and a series of bad business decisions.   When reviewing the big picture, there are some very valid reasons for NOT expanding Medicaid, and looking at how this is working in other states that have already expanded is a great place to start.  Contrary to what some may believe, only 26 states + D.C. have expanded Medicaid; with only 4 of the 8 states that border Missouri choosing to expand - Arkansas, Illinois, Iowa, and Kentucky.  In each of these cases, claims are made that more individuals are insured, which they hope will lead you to believe that access to care improved, and expanding was a positive step.  Access to coverage does not equal access to care, or quality care, and in those states that have expanded coverage, access to care, quality of care, and affordability has suffered, while the costs have surpassed all expectations.  In Arkansas, the cost increase has been so enormous that it has exceeded the Federal "cap" (as written in the expansion agreement) and the taxpayers of Arkansas are responsible for that difference.  The startling reality is that under Medicaid Expansion, hospitals actually lose more money each year to undercompensated care for those on Medicaid than to uncompensated care for those without insurance.  With the reduced mandatory costs of Medicaid, many doctors simply can't afford to accept patients covered by Medicaid, which results in too many patients for too few doctors; which is again opposite of the reported or intended effect of improving health outcomes through access to coverage.  Fewer choices for the patient directly translates into lower quality care.  Studies have shown that a patient covered by Medicaid is 13% more likely to die in surgery; or that a lung transplant patient covered by Medicaid is 29% more likely to die within 3 years following the operation.  Medicaid is clearly 2nd class care, at and above 1st class cost.  One of the biggest threats that Medicaid Expansion poses is to our state budget.  Despite the manner in which Washington operates, in Missouri we actually pass a budget that is constitutionally required to be balanced.  While the Feds promise to pay 100% for the first 3 years, the cost burden is then sharply and systematically shifted to the states; which will prompt even more difficult choices if Medicaid were expanded.  Will the newly added 300,000 individuals be dropped from coverage?  If not, then which sector of state service(s) will then have to be reduced (because the newly created costs that must fit within our budget)?  Social Services?  Education?  etc.  These are questions that remain unanswered, and are potential scenarios that would hurt all Missourians.  Not expanding Medicaid is clearly a better solution than putting ourselves in a situation where tough decisions that no one wants will be required.  Essentially what is being requested in Medicaid Expansion has less to do with helping patients and improving their care, and much more closely resembles the latest "bailout;" in which the taxpayers of Missouri are expected to pick up the tab for generations.  In the world we live in of the "kick the can down the road" mentality and the $17 TRILLION (and rising) Federal debt, I'm unsure how anyone considering the collective impact to our society, kids and country could support Medicaid Expansion.  This isn't Washington D.C., and money doesn't "grow on trees."  Someone has to pay for this and it will be YOU, the taxpayer.

For the reasons stated above, I do not support the Federal takeover of our health care system which is ObamaCare, nor do I support expanding it or the broken Medicaid system (which roughly 75% of my constituents are in agreement with); but we should touch briefly on the legislative process.  For a bill to pass the House of Representatives, it is only required to have 82 votes.  In the Senate, 18 votes are required to pass a piece of legislation, but there is a twist not available in the House; the filibuster.  On any issue and regardless of party (majority/minority), if a Senator feels compelled to the point of shutting down the Senate and the piece of legislation, he/she can speak until the bill is killed.  One Senator is all it takes.  Medicaid Expansion has 5 Senators publicly committed to filibustering any legislation that attempted expansion.  At the risk of not being diplomatic enough (I would rather be overly forward, than to be misunderstood) even though supporters may not like to hear it, those advocating for expansion at this point should realize that rather than the chances of passage hovering anywhere near 50/50; it's much closer to zero.  As in, the chance of legislation passing that expands Medicaid is zero.  Even if myself and every other Representative in the House supported expansion (which we do not, but if we did), the legislation does not have a chance in the Senate.  While discussing this issue on numerous occasions with hospital administration and their lobbyist from the Missouri Hospital Association, I have repeatedly asked, "Since it was known that ObamaCare would be harmful to everyone involved (patients, doctors, health care providers and taxpayers) where was your voice of opposition when the ACA was being written and passed?"  I have yet to receive an answer.

Unfortunately, the passage of the ACA/ObamaCare has created far more problems (which we are seeing the impacts of) than it ever purported to solve.  I support and care about our local hospital (I happen to have been born at TCMH) and am also well aware of the contributions it makes to our local economy through the families that work there and want to keep the hospital solvent to provide for our health care needs locally.  The notion that Missouri's Legislators are responsible for the consequences of ObamaCare, or the financial viability of our local hospital is simply absurd.  While significant, the amount of money not being received through the loss of DSH payments (directly resulting from the implementation of ObamaCare) is a small percentage of the hospital's total operating budget, and alone is simply not of the magnitude to result in insolvency of TCMH.  Of much greater consequence to the continued sustainability of our local hospital are the general financial administration, planning, and $20 million addition/improvement projects; which have failed to positively impact the hospital's bottom line.  Leadership and sound fiscal management play a much greater role in TCMH's potential future than any action/inaction Missouri's Legislature could take.

Contact Information:

As always, please do not hesitate to call or write me anytime with your questions or thoughts on these or any other issues. My Capitol office is 573.751.1490 and my email is  Thank you for the honor to serve as your Representative in the Missouri House of Representatives.