A Curious Hospital Argument

Everyone agrees that health care costs too much. The disagreements start when we have to decide who should receive less money. That’s a big reason why warnings about Medicaid “cuts” often receive so much attention. But the latest claims from Missouri hospitals about the One Big Beautiful Bill (OBBB) cuts hurting rural hospitals deserve a closer look.

At first glance, the concern seems straightforward. Since the government is the single largest purchaser of health care in the country, hospitals operating on thin margins could understandably struggle if they were paid less by Medicare or Medicaid. The first question, though, is what exactly is being cut.

The OBBB does not reduce the payment rates hospitals receive for treating Medicare patients or Medicaid patients who remain eligible. Instead, it implements community engagement requirements for some able-bodied Medicaid enrollees beginning next year, while changes to the provider tax financing system (explained more here) would not begin until 2028 at the earliest.

So, what are hospitals worried about? A recent KY3 report in Springfield provides some context. A spokesman for the Missouri Hospital Association explained that Medicare and Medicaid reimburse hospitals for only about 80 percent of the cost of providing care, describing the gap between costs and payments as “pretty enormous.” Mercy’s Sherry Clouse Day added that if someone loses Medicaid coverage under the new community engagement requirements, they may still seek care without insurance, leaving the hospital to absorb the cost.

That certainly could happen. But it assumes not only that a significant number of people will lose Medicaid coverage because of the new requirements, but also that many of them will become uninsured rather than finding work and obtaining employer-sponsored insurance or coverage through the Affordable Care Act marketplace.

That raises another question, though: If hospitals are already losing money treating Medicaid patients, why would treating fewer of them threaten their financial stability? Missouri hospitals already receive billions of taxpayer dollars every year through supplemental Medicaid payments and provider tax financing precisely because lawmakers recognize that Medicaid reimbursement often falls below the rates paid by commercial payers.

For those who have followed Missouri’s Medicaid debates for a while, this type of argument should sound familiar. Hospitals made similar claims during the campaign to expand Medicaid, arguing that adding more people to the program was necessary to protect rural hospitals. Today, even a policy change that doesn’t obviously reduce what hospitals are paid is being treated as a threat.

None of this is to say that lower Medicaid enrollment couldn’t result in less government money flowing to hospitals. But ultimately, hospitals are the only ones with a complete picture of how public dollars and other revenues from commercial payers affect their bottom line. After years of hospitals opposing efforts to bring greater transparency to their prices and financing, it’s fair to question yet another claim that a Medicaid policy change would threaten vulnerable hospitals. Before lawmakers accept those warnings, they should make sure there’s sufficient evidence to support the claim.

Local Issues on the Ballot in Missouri This August

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There are several cities and counties seeking to have new taxes or bond issues approved by voters on August 4. These include several major bond issues in Kansas City, a countywide use tax in St. Louis County, and sales or property tax increases in cities throughout Missouri, including in Hazelwood, Lee’s Summit, Ash Grove, and many more.

I’ll begin with the one local issue that is being voted on statewide (for various reasons that I won’t get into): Should the Jackson County assessor be an elected position? This is a pretty easy answer. Yes, it should be elected. Jackson County reassessments have been a disaster for over a decade now, and taxpayers have every right to be angry. Jackson County voters held the county executive responsible for it by recalling him, but being able to hold the assessor directly accountable is even better. St. Louis County changed its assessor from appointed to elected almost twenty years ago, and in my very informed opinion, the assessment process has improved since then. (Here are a few pieces on the general question on which positions should be elected and which should be appointed.)

St. Louis County has a countywide use tax on the ballot (again). A use tax is simply a sales tax imposed on goods you purchase online or through a catalogue and have delivered to your home. Municipal use taxes in Missouri actually predate the internet, but unsurprisingly most cities didn’t enact them until online shopping took off over the past fifteen years or so.

My view is that use taxes are a good way to expand the tax base, level the playing field for businesses, and raise local revenues. However, the last point is key. They should not be used simply as a way for cities to get more revenue, whether they need it or not. Cutting other taxes after the use tax is imposed—especially if you have a particularly harmful tax—is a great way to achieve the above benefits without a tax windfall for the county or city.

St. Louis County is having budget difficulties now, so I would understand primarily using the use tax money to address those issues. However, it would be even better if county leadership would agree to cut—at least in part—other taxes. I would suggest reducing the St. Louis County commercial property tax surcharge as a great place to start.

Kansas City is seeking approval for some substantial water and sewer bond issuances—about $750 million worth of each. There is nothing wrong with cities issuing bonds for infrastructure uses. It happens all the time, and there is a huge market for municipal bonds. If Kansas City is going to own and operate its water and sewer systems, it should invest in the system to prevent it from decaying, which is what happened to the water system in St. Louis. If that takes revenue bonds or price hikes, then so be it. (Note that these bonds will not, at least for now, require a tax increase.) So while I have no argument against approving these bond issues, I would also be remiss if I missed this opportunity to repeat that Kansas City would be even better off if it privatized its entire water and sewer system.

Remember, August 4 is a party primary election day, but you can always ask for a non-partisan ballot if you wish to vote on local ballot issues like these without voting in a party primary. The more you know . . .

Show-Me Institute Shines Light on Kansas City’s Discrimination Policies

Show-Me Institute · Kansas City’s Contracting Problem with Jonathan Whitehead

On July 22, Missouri Attorney General Catherine Hanaway filed a lawsuit against Kansas City for violating anti-discrimination laws. A copy of the suit is available here.

For some background, I recommend you read my June 18 column for The Kansas City Star. In short, I detail a city council session in which the city’s own consultants report that after reviewing seven years of contracting data, they could find no evidence to support the need for the city’s race- and sex-conscious contracting preferences. In fact, the consultancy’s director of research told the council bluntly, “You just don’t have the factual predicate” required to continue such set-asides.

What that really means is that the city has no defense against a lawsuit.

Members of the council were not pleased with the report’s findings. They could have viewed this as a huge victory for Kansas City—having reached a point where such discriminatory programs were no longer necessary. Instead, council members chose to question the results and the methodology. Mayor Lucas even offered a novel legal theory: “The courts suck.”

We know that column, the only reporting I have been able to find about the consultants’ report, played a role in Hanaway’s suit because she tells us so. Not only does the lawsuit track with what I wrote, including Lucas’s petulance, but she explicitly cites the column in the suit’s footnotes.

Following up on my column, on June 26, I spoke with Lee’s Summit–based civil rights attorney Jonathan Whitehead on KCMO Talk Radio’s Mundo in the Morning. Whitehead details the legal history regarding race- and sex-based discrimination, the rules it put in place for allowing such programs, and how the findings in Kansas City may put the city in legal jeopardy.

As with the Star column, you won’t find any such in-depth interviews on the topic anywhere else.

Missouri Doubles Down on Failed Economic Development Scheme

Gov. Mike Kehoe recently signed House Bill (HB) 3231, a broad economic development package that revives the Missouri Downtown Economic Stimulus Act, better known as MODESA.

According to the Kansas City Business Journal, the revived program could help finance an expansion of CPKC Stadium, a possible new Royals ballpark, and billions of dollars in additional development connected to Kansas City’s Power & Light District and St. Louis’s Ballpark Village.

There are other provisions in the bill, including incentives for converting vacant office buildings into housing and programs tied to designated “innovation zones.” But the return of MODESA deserves particular attention because Missouri taxpayers already have some experience with the program. In Kansas City, that experience includes the Power & Light District.

Kansas City helped champion the original MODESA program in 2003, when downtown was struggling and city leaders were looking for ways to encourage investment. The program allowed new state tax revenues generated by qualifying developments to help finance projects, including public infrastructure associated with Power & Light.

The new version could be even more generous. The Business Journal reports that MODESA could redirect 50% of incremental state sales and employee income taxes generated by qualifying projects for as long as 30 years. For certain projects, that figure could rise to 70%. Local governments also would be required to provide substantial matching incentives.

Supporters believe the program can unlock investments that otherwise might not happen. The Cordish Companies, for example, says the legislation could help support $2.5 billion in new investment in Missouri, including an expansion that could “basically double” the size of the Power & Light District.

Perhaps. But before Missouri helps double the size of Power & Light, it is worth looking at how the financing of the original project has worked.

The district undoubtedly helped change the face of downtown Kansas City. It brought restaurants, bars, and entertainment venues to an area that badly needed investment. But it didn’t create new investment—it merely redirected economic activity at bars and restaurants from elsewhere in the city to downtown.

We know this because data provided by the city’s Regulated Industries Division shows us that the number of liquor licenses and employee cards required of bartenders and waitstaff remained flat after Power & Light opened. Despite new shops downtown, there was no growth citywide.

To make matters worse, the district has not generated enough revenue for Cordish to cover its debts. Because then-Mayor Kay Barnes was foolish enough to put taxpayers on the hook for debt payments, Kansas Citians have been paying out about $12 million each year over and above the tax revenue we divert back to the developer.

Kansas City is considering using the revived MODESA program as part of financing packages for an 18,000-seat expansion of CPKC Stadium and potentially a $3 billion Royals ballpark development at Crown Center. The city already has signaled its willingness to consider as much as $235 million in local incentives associated with the current project and $600 million for the Royals.

The state incentives are not insignificant, either. According to the Business Journal, the fiscal note for HB 3231 estimates the legislation will cost Missouri more than $62 million annually once fully implemented in 2034.

As Missouri leaders take on the task of cutting spending so that they may reduce and eventually eliminate the state income tax, these types of subsidies are not a sign of fiscal seriousness.

We’ve been here before. The effort failed. Why are we doubling down?

Missouri Earns a “B” on Cell-Phones-in-Schools Report Card

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Missouri received a “B” on a national report card evaluating state policies on cell phone use in schools. This grade, available at phonefreeschoolsreport.org, places Missouri in the top half of states.

The primary reason for Missouri’s strong grade is its bell-to-bell ban on student cell phone use during the school day. State law also protects school employees from liability when they act in good faith to enforce the policy.

Missouri fell short of an “A” grade because students are allowed to store their phones in an accessible place during the school day. Only four states received “A” grades—Indiana, Kansas, North Dakota, and Rhode Island. They all require phones to be stored in an inaccessible location.

Overall, Missouri’s “B” grade is good news. Our lawmakers deserve credit for moving early on an issue where both common sense and research point in the same direction. Removing phone access during the school day is a straightforward solution to the obvious distractions that students’ devices bring into the classroom.

That said, our policy can be improved. When phones remain within arm’s reach—inside backpacks or pockets—there is temptation to use them. Requiring inaccessible storage would make enforcement easier and reduce classroom disruptions further. It would also align Missouri with the strongest policies in the country.

Missouri has taken an important step toward phone-free classrooms. Strengthening the law to require inaccessible storage would help get the most out of our students during school.

New Budget, New Problems

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Imagine getting a large one-time bonus, then using that money to buy an expensive new car. There are some obvious parallels to Missouri’s budget.

Shortly before the June 30 deadline, Governor Kehoe signed Missouri’s more-than-$50-billion budget for fiscal year 2027, which began on July 1. He also issued about $53 million in vetoes and more than $400 million in spending restrictions. While the vetoes are generally in line with recent years, the expenditure restrictions are much larger than have been necessary in more than a decade. The restrictions also indicate that the governor believes the legislature approved roughly $400 million more in spending than projected state revenues can support.

Unlike a veto, a spending restriction doesn’t permanently eliminate an appropriation. Instead, it temporarily withholds the authority to spend it. Missouri’s constitution requires the governor to keep the budget balanced throughout the fiscal year, so if projected revenues won’t support all the spending approved by the legislature, the governor must reduce authorized spending through vetoes, restrictions, or a combination of both. The difference is that vetoes are permanent unless the legislature overrides them, while restrictions can be lifted if revenues improve. The governor then decides which restricted appropriations, if any, are ultimately released.

Perhaps the most interesting part of the governor’s budget signing was the explanation he provided for this year’s actions. Kehoe reiterated something he’s said before: Missouri has a spending problem rather than a revenue problem. He also said the state needs to reduce its reliance on what are called general revenue pickups. General revenue is the state’s primary operating fund, supported largely by income and sales taxes. A general revenue pickup occurs when a temporary funding source disappears, leaving general revenue to cover an ongoing expense. That’s exactly how temporary spending becomes a permanent obligation.

The governor’s explanation reflects two concerns I’ve written about repeatedly. First, Missouri’s spending has been growing faster than its revenues. As the auditor has highlighted, between fiscal years 2020 and 2025, general revenue collections increased 45.8 percent. During that same period, general revenue spending increased 53.4 percent, more than double the rate of inflation.

Second, lawmakers treated the surge in temporary federal COVID relief and an extraordinary period of state revenue growth as an opportunity to expand ongoing commitments. As those temporary dollars disappeared, the state became increasingly reliant on general revenue pickups, shifting costs that had once been covered by other funding sources onto Missouri taxpayers.

Remember the car? If soon after your purchase you found you couldn’t afford your new car, nobody would say you had an income problem. They’d rightfully say you spent too much. Missouri’s budget shouldn’t be viewed differently. The good news is that Governor Kehoe’s actions indicate he has correctly identified the problem. Now it’s up to lawmakers to get serious about solving it.

Technology and Our Children: “They’re almost like addicts”

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Most schools embraced digital learning during and after the COVID pandemic, dramatically increasing students’ screen time during the school day. Combined with the long hours many children already spend on screens outside of school, the result has been an unprecedented amount of daily screen exposure.

But people are starting to push back. More than half of states have policies that limit or fully ban cell phones in schools. And many states and school districts have also enacted, or are considering, policies that limit screen use for instruction. Patrick Johann recently reviewed an instructional-use screen time policy adopted by the Los Angeles Unified School District, which is scheduled to take effect this upcoming school year.

Missouri is part of this broader trend. Last year the state banned cell phone use during the school day, and lawmakers debated the Student Screen-Time Standards Act during the 2026 legislative session, which would have curbed screen use for instruction. The Student Screen-Time Standards Act didn’t pass into law, but similar legislation will almost surely be introduced in 2027.

The rationale for cell-phone bans is that cell phones are a distraction. For laws that limit screens for instructional use, the idea is that screen-based instruction simply does not produce as much learning as face-to-face teaching. Technology offers many benefits, but it has been unable to replace the human interaction that many students—especially those from disadvantaged backgrounds—need to thrive in school.

If we had a robust market for school choice, I would welcome schools that make technology central to their instructional model. Some students will undoubtedly flourish in those environments, and technology can support a level of personalized instruction that is difficult to achieve in a traditional classroom. Alpha School is an interesting model with promising early results.

But in states like Missouri, where most students are still required to attend their residentially zoned public school, school districts should not use learning models that don’t benefit most students.

A recent article at The74 discusses an unlikely ally in all of this: students themselves. The article explains how many students describe their relationship with technology in terms that resemble addiction. The author writes:

They don’t want to be on their phones eight or nine hours a day. They don’t want to use AI to complete their assignments and short-circuit their ability to learn and grow. They know their attention span is stunted. But in so many circumstances, they simply can’t resist.

When the pandemic hit, schools shifted quickly toward technology-based instruction. It all happened very fast. However, as is often the case in such circumstances, the pendulum may have swung too far. Perhaps the clearest sign is the growing consensus for a course correction—from parents to teachers to policymakers and, increasingly, to students themselves.

How Much Will the New Federal Scholarship Tax Credit Boost School Choice Funding?

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The federal government will roll out a new tax-credit program in 2027 to expand school choice. Taxpayers will be able to receive a dollar-for-dollar federal tax credit for donations of up to $1,700 annually to a scholarship-granting organization (SGO) in Missouri—or any other participating state. The SGO then distributes scholarships to families seeking alternatives to their residentially assigned public schools.

In a previous post I wrote about the new program, focusing on the challenge of deciding which educational expenses should qualify for scholarship funding.

Over at Education Next, Rick Hess has a thoughtful piece on other aspects of the program. As both a school choice advocate and an advocate of fiscal responsibility, he opens with a concession, acknowledging the potential loss of tax revenue the program could create at a time when the federal debt is growing rapidly.

He then makes what I think is the right point: While it is unfortunate that the federal budget is off the rails, it is hard to get too worked up about this program when (a) it is a drop in the bucket compared to our broader fiscal problems, and (b) so much of our debt-financed spending benefits older Americans. If we’re going to keep borrowing, why not direct at least a small share toward expanding opportunities for children?

I share Hess’s bottom-line sentiment. I wish the federal government managed its finances more responsibly. But since that does not appear likely anytime soon, investing a bit more in the children who will ultimately inherit—and help repay—that debt seems sensible to me.

Turning to the program itself, Hess raises an important practical concern. Even though this is a dollar-for-dollar tax credit, which means it is effectively costless for taxpayers to participate, we should not assume it will be widely used. Many taxpayers may be unaware the credit exists. Others may doubt they’ll actually receive it or may not know how to make a qualifying donation to an SGO. Even modest uncertainty or inconvenience can discourage participation.

These are legitimate concerns. The new scholarship tax credit has the potential to generate substantial resources to expand school choice, but realizing that potential is not automatic. As Hess puts it, “I don’t put a lot of stock in the casual assurance that taxpayers will jump through hoops to give money away simply because, as one very prominent champion explained to me, ‘It’s a good thing to do.’”

Hess’s piece points to one of the program’s biggest implementation challenges. Helping taxpayers understand the credit—and making participation as simple as possible—could make an enormous difference. Show-Me Institute analysts will certainly be doing our part, and I hope many others will as well.

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