David Stokes, Elias Tsapelas, and Avery Frank join Zach Lawhorn to discuss the expiration of enhanced Affordable Care Act subsidies, new federal proposals aimed at lowering healthcare costs through cost sharing, employer coverage reforms, and prescription drug transparency. They also break down the latest installment of David Stokes’ Free Market Guide for Missouri Municipalities on parks and recreation, the role of user fees and outsourcing, national polling on public school open enrollment and why parents strongly support it, what they are watching as the 2026 legislative session approaches, and more.

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Link to the national survey: yeseverykidfoundation.org/new-national…2-education/

Produced by Show-Me Opportunity

The post ACA Subsidies, Parks Policy, and Open Enrollment in Missouri appeared first on Show-Me Institute.

Over the past several months, I’ve written about the many changes coming to Missouri’s welfare programs as a result of the One Big Beautiful Bill (OBBB). One of the most impactful changes involves the Supplemental Nutrition Assistance Program (SNAP). In short, if Missouri doesn’t get its SNAP payment error rate below 6%, state taxpayers will start paying for a portion of the program’s benefit costs (the federal government currently covers 100% of benefits), which could potentially increase the state taxpayer cost to $400 million per year. A similar change is coming to Medicaid.

Despite accounting for roughly one fifth of total U.S. healthcare spending, Medicaid has until now lacked stringent federal accountability for payment errors. Just last year, more than $31 billion in improper payments were made across the program according to the U.S. Department of Health and Human Services (HHS). The OBBB requires HHS to reduce state Medicaid matching payments (more here on how Medicaid is financed) starting in 2030 when improper payment rates exceed 3% of total Medicaid expenditures.

Missouri should be particularly concerned about this change. In 2022, when the state’s Medicaid program was last audited by the federal government, its improper payment rate was 4.2%, which already exceeded the new 3% threshold. And there’s little reason to believe things have improved since then. Just last month, I wrote about the recent state audit showing that Missouri lacks systems to check enrollees against death records and that thousands of recipients went years without having their eligibility verified.

The financial implications for Missouri could be substantial. With more than one in five Missourians now on the program and Medicaid already consuming a massive portion of the state budget, even a small reduction in federal matching payments could force state taxpayers to cover millions more in costs.

The good news is that Missouri has more time to address this than it does for SNAP. The bad news? Given the state’s track record on technology modernization and the sheer volume of problems that need fixing, there’s plenty of reason for skepticism about whether Missouri will rise to the challenge.

While the OBBB’s focus on program integrity might be a nuisance for state bureaucrats, there’s no doubt that a corrective measure is long overdue. Taxpayers shouldn’t be burdened with millions (or perhaps billions) in new Medicaid costs because our state can’t get its improper payments under control.

The post Medicaid’s Wake-Up Call appeared first on Show-Me Institute.

Susan Pendergrass is joined by Elias Tsapelas, director of state budget and fiscal policy at the Show-Me Institute, to explain what was actually at stake in the recent federal government shutdown. They break down the debate over extended Affordable Care Act subsidies, why health insurance costs keep rising, how COVID-era provisions distorted the marketplace, and what Congress may do next.

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Timestamps

00:00 Understanding the Government Shutdown
06:31 The Debate Over ACA Subsidies
09:10 Impact of the Affordable Care Act
13:24 Proposals for Health Care Reform
17:53 The Future of Health Care Costs

Transcript

Susan Pendergrass (00:00)
Well, this is going to be a very timely and interesting conversation with the Show-Me Institute’s own Elias Tsapelas. You are the Director of State Budget and Fiscal Policy, two things that are front and center right now, but I really wanted to just have you on to talk about a little bit of stuff around the recent government shutdown.

And I just want to say upfront, if I understand this correctly, the federal government can’t pay its bills unless it’s got an approved budget to pay the bills, right? And the fiscal year runs October 1st to September 30th. And if you don’t have a new budget for the next year, you can’t pay your bills. So it’s up to the Senate, the House, and the President to agree on a budget. And this past September, as has happened before, they could not agree, and Democrats were holding out, and that caused the government to shut down. What were Democrats saying they were holding out for?

Elias Tsapelas (00:52)
Well, I guess I should start with just a little caveat that some of what the Democrats were saying they were holding out for was not precisely what was on the table. So no matter what happens, health care premiums are going to be going up, that’s just a fact, because health care costs are up. Health care costs are going up everywhere. Hospitals, Medicaid, we see it everywhere.

Susan Pendergrass (00:56)
You know, fix it up for me. Why?

Elias Tsapelas (01:20)
What they were holding out for were these extended or expanded ACA subsidies, Affordable Care Act subsidies. We’re talking about the marketplace here. This is typically for people making between 100 percent and 400 percent of the federal poverty limit. For example, a couple of two: 100 percent of the federal poverty limit is about $21,000 per year, 400 percent is about $85,000 per year. That’s roughly the range you’re looking at.

Now, some small employers do purchase plans through the marketplace, but the big piece here is that the ACA provides subsidies for people. And the way it works, essentially, is that people pay a proportion of their income. If your income is 100 percent of the federal poverty limit, you’re going to pay roughly 2 percent of your income. Now, there are extended subsidies that change that calculation. But the point being, the law set out that if you make this amount of money, you’re only going to pay this much on health insurance, and the government is going to subsidize the rest. You are not sensitive to costs at all, because your costs are tied to your income.

Susan Pendergrass (02:54)
So, for example, if you earn $4,000 a month, theoretically, and I don’t know the numbers, the government would say you won’t pay any more than $300 in insurance premiums?

Elias Tsapelas (03:05)
Yep. And so that is a percentage that you pay scaled off how much income you have from that 100 to 400 percent. That is a core piece of how the Affordable Care Act worked, and everyone paid a portion based on the base subsidies.

Now, what the debate was about, or what Democrats were holding out for, was expanded subsidies, which came about during COVID as part of the American Rescue Plan, ARPA. And it did a couple things, but they were subsidies on top of regular subsidies. So this was not, “If this doesn’t happen, everyone is going to be paying unsubsidized plans.” This was an additional type of subsidy. These additional subsidies were set to expire at the end of the year, at the end of December. ARPA gave four years of subsidies.

Susan Pendergrass (04:04)
Because it was COVID related, temporary, and they said, “We’ll cover more of your premium through December 31, 2025.”

Elias Tsapelas (04:14)
Yes, I think part of the calculation was that people were going to like it so much that it would be hard to get rid of. And it’s certainly the case: if these subsidies go away, people will be paying more.

Susan Pendergrass (04:15)
Ahem.

Elias Tsapelas (04:27)
But that is not to say there would be no subsidies at all. These extended subsidies did a couple things. For people between 100 and 150 percent of the federal poverty limit, quick caveat: in Missouri, if you make under 138 percent, you’re on Medicaid, so you don’t pay anything, but in many states without Medicaid expansion, people go on the marketplace. What these expanded subsidies did is: if you made between 100 and 150 percent of the federal poverty limit, you paid zero percent of your income. You got a plan for free.

You would still have some cost sharing, and the sliding scale up to 400 percent that the normal subsidies used was lowered, so people under regular subsidies who made 400 percent of the federal poverty limit were paying about 10 percent of their income. With the expanded subsidies, you’d only pay 8.5 percent, and the subsidies no longer stopped at 400 percent. They would go all the way up. You would never pay more than 8.5 percent of your income.

Susan Pendergrass (05:30)
Okay.

Elias Tsapelas (05:42)
But typically, people above 400 percent of the federal poverty limit don’t want to buy ACA plans because 8.5 percent of income is expensive. Still, a decent number of people were impacted. It costs a decent amount of money. The Congressional Budget Office says extending these expanded subsidies costs about $350 billion over 10 years. Very expensive. But there are a lot of issues here, which Republicans are pushing back on as they negotiate whether to extend these by the end of the year.

Susan Pendergrass (06:31)
So now we’re in this argument of whether we extend COVID subsidies or not. And like you said, Republicans seemed willing to say maybe a year, or maybe we’ll vote on it in December. Essentially the Democrats didn’t get any of what they asked for, right?

Elias Tsapelas (06:48)
Yeah. A key piece is that when Democrats passed this in ARPA, no Republicans voted for it. There’s a variety of reasons, but a big one is that it exacerbates problems with the Affordable Care Act. People buying health insurance are seeing higher prices, high deductibles, high copays, so people don’t want to buy it. These additional subsidies got more people into the market, but at a very expensive cost. And because people are not cost sensitive, their share is tied to their income, the subsidies scale regardless of what insurance companies charge. That creates unintended effects. There were allegations of fraud. And a larger discussion: if we’re going to spend $350 billion per 10 years, is there not a better way to get healthier people to buy health insurance? Is there a better way to help people?

And the people most impacted are those around 400 percent of the federal poverty limit, not very low income people. Higher income people. And often near retirement folks who aren’t working anymore but aren’t yet on Medicare. They need health insurance, they have health needs, and insurance gets very expensive. That was something the Affordable Care Act tried to deal with. But doubling down on continuously funding this subsidy system is something Republicans didn’t want to do.

Susan Pendergrass (09:10)
Yeah. So we had Brian Blase of Paragon on the podcast, and he absolutely did not want those COVID related subsidies extended. He claimed that the Affordable Care Act caused health related expenses to go up. Do you know how that works?

Elias Tsapelas (09:45)
There are a couple things going on. One big thing Brian talks about is likely enormous fraud from the expanded subsidies. Bloomberg had a good article about what happened in Florida. As soon as the federal government offered zero premium plans for people between 100 and 150 percent of the federal poverty limit, background: Florida hasn’t expanded Medicaid, so people enroll on the marketplace. What happened is that it became a business for insurance brokers to get people enrolled. Brokers make money off enrollments, and people don’t care if they aren’t paying premiums.

So you had an enormous increase in people supposedly making between 100 and 150 percent of the federal poverty limit. Census data suggests far fewer people actually make that income. Tons were getting health insurance for free, and many weren’t using it. You’d expect higher usage. There are reasons to think there was widespread fraud.

More broadly, ACA plans must cover many things people don’t need, which drives up costs. And the marketplace risk pool is heavily made up of sick people, fewer healthy people, which makes insurance expensive.

So the bigger discussion is: how do you get healthier people into the market? How do you offer plans people want? Republicans are taking a stand that doubling down on the ACA model, with subsidies disconnected from costs, won’t work long term.

Susan Pendergrass (13:24)
Correct me if I’m wrong on this, but didn’t Senator Thune or somebody suggest just sending people $5,000?

Elias Tsapelas (13:30)
I don’t know if it was exactly that amount, but yes, there have been proposals essentially saying: maybe there will need to be a one year extension of subsidies because new plans start soon and it would be hard to roll out big changes in a month. But some ideas, from Senator Cassidy, Senator Thune, and others, propose approving the same amount of money but sending it directly to people instead of insurance companies. For many people, subsidies are worth over $30,000 a year. If people got $30,000, they might not spend it all on an ACA plan costing that much. They might buy a cheaper plan, use out of pocket spending, or seek non ACA compliant plans. There are ideas: HSAs, short term plans, specialized plans. A key piece is giving the money to people, not insurance companies, so someone has an incentive to reduce costs.

Susan Pendergrass (15:47)
Yeah. Well, the shutdown ended. Nothing really changed, right?

Elias Tsapelas (15:52)
Yeah. Congress will have to work a lot in the last month of the year. I’m a little disappointed. There were almost some very interesting budget related court cases that could have come from the shutdown. One argument was whether the government must fund food stamps, or SNAP, during a shutdown, whether they must give out money not appropriated. Some judges said yes. That raises major questions: can courts tell the executive branch to spend money Congress didn’t appropriate?

Susan Pendergrass (16:54)
I think they were told that they don’t, right, in the end?

Elias Tsapelas (16:59)
The Supreme Court basically said courts needed to wrestle with the issue. It got resolved before a final answer. We don’t know for now. Judges were on different sides. Democrats pushed back noting that in previous budgets, they fought to fund things, but the executive branch simply didn’t spend the money. There’s a lot of interesting stuff: can courts force funding, can the executive disregard congressional appropriations? I’m upset that didn’t get resolved. But the ACA issue is big enough that Congress has its hands full.

Susan Pendergrass (17:53)
Some folks said that because of the SNAP benefit question, we were just getting to the point where Americans were paying attention to the shutdown and then it ended. And what’s interesting is the amount of misinformation and hard to follow information. I saw headlines about someone’s insurance premiums going from $300 to $2,600. I don’t know if any of that was right, but it got a lot of play.

Elias Tsapelas (18:28)
I don’t think it was covered especially well in terms of what was being argued, because the government shut down far before these subsidies expired. There was a lot of muddying of the waters. Some people thought if subsidies weren’t extended, no one would have subsidies, even though the people most impacted would just go from paying 8.5 percent of income to 10 percent. Not nothing, but not catastrophic.

Health care costs are going up broadly. Medicare enrollees are getting renewal notices. Everything is going up. ARPA was designed to be temporary. If it were supposed to be permanent, Congress could have made it permanent. Whether Democrats thought it would be continued forever or just help temporarily is unclear. But if Congress comes up with something that makes health insurance better, I’m all for it. There are tough decisions. Congress has struggled with ACA reform for a decade.

Susan Pendergrass (20:20)
I think we know the answer to that. At the federal level, when they want to do big splashy things, ARPA, the ACA, the Tax Cuts and Jobs Act, they make expenses short term to reduce the fiscal note, assuming someone will renew them later. Same thing with the Tax Cuts and Jobs Act. They assume future lawmakers will extend them. So it’s not unreasonable that ARPA had temporary provisions assuming they’d get extended. I guess not this time.

Elias Tsapelas (21:12)
People’s health care costs going up is a big issue. People won’t be happy regardless. But returning to issues that should have been addressed when the ACA passed is important. The marketplace is dysfunctional and too expensive. Hopefully Congress finds something better. And I don’t want to minimize issues for people close to retirement. That’s a big issue: people between 55 and 65, not on Medicare yet, often have significant health needs. If you tell a 60 year old who isn’t working that coverage is $40,000 a year, that won’t work.

Susan Pendergrass (21:53)
Yeah. That’s right.

Elias Tsapelas (22:23)
More options will be good. That is an important group that needs to be addressed.

Susan Pendergrass (23:07)
Well, thanks for explaining it so clearly and helping our listeners understand what was actually on the table. It’s a complicated topic, but we’ll watch it unfold over the next year, and hopefully you’ll come back and explain what’s happening as it unfolds.

Elias Tsapelas (23:23)
Hopefully something does happen, so there is something to explain. That would be the best case scenario.

Susan Pendergrass (23:25)
That’s right. All right, well, thanks so much, Elias. Really appreciate it.

Elias Tsapelas (23:31)
Thank you.

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The post What the Government Shutdown Was Really About with Elias Tsapelas appeared first on Show-Me Institute.

Created, at least in part, to help states deal with the reining in of Medicaid provider taxes, the fund guarantees each state $500 million (half of the $50 billion divided by 50 states), but the other half ($25 billion) is going to be awarded based on a scoring system the federal government recently rolled out. Most notable among the recently published scoring criteria are points for enacting many of the free-market healthcare reforms my colleagues and I have been writing about for years.

The scoring system doesn’t just assess demographics or the number of rural hospitals, though they are a big part of the rubric. It also awards states points for policy changes that reduce red tape and open the door for better care. Some of these items include repealing certificate of need (CON) laws, expanding scope of practice for nurses and other healthcare professionals, improving short-term health insurance options, and making telehealth more accessible. Missouri has debated each of these ideas for years, and made some progress, but now enacting these meaningful reforms has additional monetary stakes.

Despite recent incremental progress on the free-market healthcare front, there’s still a lot that Missouri could do. Our CON laws are some of the worst in the country. They stifle healthcare competition by forcing providers to receive permission, often from their competitors, before adding new hospital beds, building new facilities, or even purchasing certain types of equipment.

Scope of practice restrictions are another self-inflicted wound I’ve written a lot about in the past. Missouri gives advanced practice registered nurses less autonomy than in many other states. Our state already has a shortage of healthcare providers, and removing those restrictions would help improve healthcare access, make Missouri jobs more competitive, and ultimately lower costs—all without sacrificing patient safety.

On the telemedicine front, Missouri has made progress by expanding services to audio-only technologies earlier this year but has the potential to go much further. More flexible rules on prescribing and treating patients could dramatically expand access for families, especially for those in rural communities.

At the end of the day, many of the reforms incentivized by the OBBB are policies Missouri should have adopted years ago, but the federal funding offers lawmakers a new reason to finally take action. If Jefferson City seizes this golden opportunity, Missouri can both improve the state’s healthcare policy and score some additional resources that could help in these tough budgetary times. That sounds like a rare win-win to me.

The post Reform First, Dollars Second appeared first on Show-Me Institute.

Susan Pendergrass is joined by Elias Tsapelas, director of state budget and fiscal policy at the Show-Me Institute, to break down the sweeping new federal legislation known as the “One Big Beautiful Bill.” They discuss what it really means for Medicaid recipients, food stamp programs, state budgets, and Missouri taxpayers.

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Timestamps

00:00 Understanding the One Big Beautiful Bill Act
06:44 Medicaid: Changes and Implications
11:23 SNAP Benefits: New Regulations and Effects
14:18 Tax Implications for Missourians
19:09 Future of Medicaid and State Budgets

Episode Transcript: Understanding the One Big Beautiful Bill with Elias Tsapelas (Download Here) 

Susan Pendergrass (00:00)
Okay, here we go. You ready? Elias Tsapelas, we are going to talk about IT—the big IT—the One Big Beautiful Bill Act. I don’t feel like I understand it. I suspect there’s a lot of people reading the news that don’t understand it, but you seem to understand a lot of it. So thanks for coming to talk to us about it today.

Elias Tsapelas (00:19)
No problem. I think there’s a lot of misconceptions, especially about what’s happening with the welfare programs in the bill. So I’m happy to dive into those.

Susan Pendergrass (00:27)
Yes, yeah. I’ve definitely seen claims that this is going to basically strip health care from millions and millions of people and that kids will be hungry. And I don’t want to minimize that. But we had Brian Blase on the podcast, and I thought I had an understanding of it that didn’t exactly line up with that narrative. So let’s just start there. People are saying that tens of millions of people are going to lose health insurance under the One Big Beautiful Bill Act. Explain that to me.

Elias Tsapelas (01:01)
Well, the first thing people need to understand about Medicaid is that it’s gotten tremendously more expensive in recent years. The Biden administration made a lot of changes during COVID—changes to how the program works and its future trajectory. Even after the One Big Beautiful Bill goes into effect, we’re basically just putting the program’s costs back on the trajectory it was on in 2021. This isn’t going back to the Stone Age—it’s more like going back five years.

A lot of this stems from efforts to eliminate waste, fraud, and abuse. And while there’s certainly some of that, what many people don’t realize is that most states, including Missouri, now contract with private health plans to cover people on Medicaid—particularly the Medicaid expansion population, which consists of healthy adults.

Susan Pendergrass (02:11)
Okay, so let’s just pretend we know nothing. Medicaid is a program that covers health insurance costs for low-income and disabled individuals?

Elias Tsapelas (02:24)
Yes. About 50% of kids in Missouri are on Medicaid. The program covers around two-thirds of all nursing home costs and over a third of all births in the state.

Susan Pendergrass (02:34)
So low-income pregnant women can get Medicaid coverage, and their children can as well. Who exactly is in the “expansion population”?

Elias Tsapelas (02:47)
Good question. And just to clarify—yes, Medicaid also covers a lot of very disabled individuals who private health insurance wouldn’t. But the expansion population refers to healthy adults making up to 138% of the federal poverty limit. These are not permanently disabled people. They’re generally able to work.

Before 2021, someone like me—unmarried and childless—couldn’t qualify for Medicaid in Missouri, even if I lost my job. Medicaid expansion changed that, and with it came a lot of problematic incentives. One issue is that states are paying health plans monthly for enrollees, but there isn’t always a process to verify whether those people are still eligible.

Susan Pendergrass (04:53)
Let me just stop you there. So the state is paying monthly premiums for people who might not even know they’re on Medicaid? And they might have a job now and no longer qualify, but the state hasn’t gone back to check?

Elias Tsapelas (05:40)
Exactly. Ideally, people would notify the government when they get a job, but most don’t, and the IT systems don’t really catch that. Previously, states just paid the bills as they came in. If someone didn’t go to the doctor, there was no cost. Now we’re paying premiums whether they use care or not, which adds up quickly.

Susan Pendergrass (06:40)
So what’s in the One Big Beautiful Bill? Are states required to recertify people?

Elias Tsapelas (06:45)
Yes. One big provision is that states must check eligibility at least twice per year. The Congressional Budget Office projects significant enrollment losses just from checking more often. That’s raised concerns about red tape, but the goal is to ensure people who are no longer eligible aren’t still receiving coverage.

Susan Pendergrass (07:13)
Can Missouri do that? Do we have the systems in place?

Elias Tsapelas (07:20)
I’d like to think so, but I’m not sure. During COVID, states weren’t allowed to check eligibility at all for over three years. Missouri spent an entire year catching up when that ended. Right now, about 1.2 million people are on Medicaid in Missouri, including 350,000 in the expansion group. So yes, it would mean more IT strain.

Another major part of the bill is requiring “community engagement” or work requirements for the able-bodied expansion group.

Susan Pendergrass (08:24)
So that’s people under 65 who aren’t disabled? How do they know who’s supposed to work?

Elias Tsapelas (08:32)
There are carve-outs—new moms, parents with kids under 14, people over 65, etc. The idea is to target people who could be in the workforce. There are also alternative ways to meet the requirements, like volunteering. And it’s worth noting: the SNAP program (food stamps) has had work requirements since the 1990s.

Susan Pendergrass (10:25)
Then why are people saying this will “kick people off”?

Elias Tsapelas (10:33)
Because people will have to meet work or volunteer requirements, and the state will recertify them more often. The question is: how many people will get caught in red tape? That depends on how well states implement the changes. Most of the bill’s provisions are phased in over time to allow states to adapt.

Susan Pendergrass (11:34)
Let’s talk about SNAP benefits. People are saying this will take food away from families. What’s actually changing?

Elias Tsapelas (11:46)
The federal government will now penalize states with high error rates in SNAP administration. Missouri’s overpayment error rate is about 10%, and some states are worse—Alaska’s is nearly 25%. Under the bill, if your error rate is over 6% for two years, the state will have to start covering some of the cost. So Missouri may have to pay a portion of benefits if it doesn’t improve.

Susan Pendergrass (14:06)
How does the bill impact taxes for Missourians?

Elias Tsapelas (14:14)
The standard deduction is going up—by $750 for single filers and up to $6,000 more for seniors. There’s also a new deduction for car loan interest and temporary exemptions for taxes on tips and overtime. Since Missouri’s tax code follows the federal code, that could mean less state revenue, too.

Susan Pendergrass (15:41)
So what will this cost Missouri?

Elias Tsapelas (15:46)
It depends. If we reduce our SNAP error rate, the cost isn’t too bad. But a bigger issue is the provider tax cap dropping from 6% to 3.5% over a few years. Missouri is at 4.2% now, so we’ll need to lower it. That tax generates about $1.5 billion per year for hospitals.

Susan Pendergrass (17:09)
How does the rural hospital fund come into play?

Elias Tsapelas (17:24)
The bill creates a $50 billion Rural Hospital Fund to be distributed over five years. States will get a portion based on how rural they are. The hope is this fund offsets the provider tax losses—at least through 2030. But after that, the fund ends. So there’s concern about what happens long-term.

Susan Pendergrass (19:18)
Senator Josh Hawley mentioned he supports the bill but hopes to fix the provider tax issue in five years.

Elias Tsapelas (19:29)
That seems to be the thinking—pass it now and revisit the unpopular parts later. A lot of the tax and spending changes are temporary, which is partly how they got the bill to comply with budget rules.

Susan Pendergrass (20:30)
This reflects what voters asked for—smaller government and more state responsibility. It reminds me of the Department of Education cuts. Missouri will have to decide which programs to keep and how to fund them. But I was surprised the expansion of the MOScholars tax credit program made it in.

Elias Tsapelas (22:35)
Yes, Medicaid will continue to dominate the state budget if we don’t address it. Every year it’s, “How much more is Medicaid going to cost?” Then we build the rest of the budget around that. This bill will force Missouri lawmakers to reevaluate some of those assumptions and perhaps reconsider whether managed care is working.

Susan Pendergrass (25:02)
That’s going to be interesting to watch. Thanks for breaking it down, Elias. This bill is being talked about a lot, but I think a lot of people are still unsure what it really does.

Elias Tsapelas (25:16)
No problem. I think we’re all looking forward to seeing what happens next.

Produced by Show-Me Opportunity

The post Understanding the One Big Beautiful Bill with Elias Tsapelas appeared first on Show-Me Institute.

Senate Bill (SB) 79 will (if Governor Kehoe signs it), among other things, expand the definition of “telehealth” or telemedicine to include audio-only and audiovisual services. On its face, SB 79 may not seem like the biggest or most impactful change, but it addresses a major problem with Missouri’s telemedicine laws that has been needlessly restricting access to care for years.

A few months ago, I wrote about several ways in which healthcare access for Missouri residents could be improved, and abandoning the requirement for video in cases where it isn’t medically necessary was one of the policies I highlighted. There are still large parts of Missouri without reliable broadband internet access, and not everyone has a phone or computer capable of transmitting video. Further, not every medical treatment requires a visual examination (for example, mental health services). Given our state’s well-documented shortage of healthcare providers, any effort to improve healthcare access without sacrificing safety or quality of care is welcome.

It’s easy to forget that back during the COVID-19 pandemic, Missouri ranked among the national leaders in telemedicine access. Various laws and regulations were waived for emergency response purposes, allowing patients to access their providers virtually with more ease than ever before. In turn, telemedicine grew tremendously in both functionality and popularity, among patients and providers alike—until the emergency ended and many of the unnecessary regulatory burdens telemedicine previously faced were allowed to return.

After several years of telemedicine reform nearly reaching but failing to cross the finish line, SB 79’s passage feels like a long time coming. As states across the country continue improving their licensing laws to expand healthcare supply and account for changing technology, Missouri could no longer afford to keep reform on hold. And while the bill doesn’t address all of the areas in which I think Missouri’s telemedicine laws could be improved, it does represent a small, important step in the right direction.

Going into next year, there is still plenty of work to be done to improve Missourian’s access to care. Hopefully, SB 79 is a signal that our lawmakers are dialing up more expansive healthcare reforms for 2026.

The post Missouri Finally Dials in Telemedicine Reform appeared first on Show-Me Institute.

In this episode, Susan Pendergrass is joined by Brian Blase, president of Paragon Health Institute, and Elias Tsapelas, director of state budget and fiscal policy at the Show-Me Institute, to break down the health care provisions in the “One Big Beautiful Bill.”

They focus specifically on the bill’s Medicaid provisions, including efforts to enforce eligibility checks, freeze the growth of provider tax schemes, and reduce improper enrollment. Blase and Tsapelas also discuss the reality behind claims that millions will lose coverage, the true cost of Medicaid expansion, and the perverse incentives that allow states to game the federal reimbursement system.

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The post The One Big Beautiful Bill’s Impact on Medicaid with Brian Blase and Elias Tsapelas appeared first on Show-Me Institute.

Here’s an overview of some of the legislation passed this session (some of which is still awaiting the governor’s signature):

$50 MILLION FOR MOSCHOLARS PROGRAM

• First public investment in the K–12 scholarship program, with $50 million approved in the state budget
• Could triple the number of students served, expanding access to private school, homeschooling, and
specialized support

TELEHEALTH AND HEALTH CARE REFORMS: SB 79

• Improves telehealth access by allowing both audio-only and audiovisual services on any HIPAAcompliant
platform
• Expands health benefit offerings by allowing certain organizations to offer health plans to members,
sometimes referred to as farm bureau or association health plans, without many of the burdensome state
and federal restrictions that apply to traditional insurance offerings

PROTECTING PROPERTY RIGHTS: HB 595 AND HB 343

• Prohibits cities and counties from requiring landlords to participate in voluntary federal housing
programs such as Section 8 housing vouchers
• Bans caps on security deposits and restrictions on tenant screening criteria like income, credit, and
criminal history

CAPITAL GAINS TAX EXEMPTION: HB 594

• Exempts 100% of long-term capital gains from Missouri state income tax for individuals
• Applies to all individual income reported as capital gains for federal tax purposes, starting tax year 2025
• Designed to encourage investment and entrepreneurship by reducing the tax burden on productive
activity

EXPANDING LICENSE PORTABILITY: SB 150

• Expands access to temporary occupational licenses across most licensed professions in Missouri by
repealing the harmful compact exemption, ensuring that more professionals moving to Missouri can
start working without unnecessary delays
• Provides expedited occupational licenses to law enforcement spouses moving to Missouri, allowing
those licensed in another state for at least one year and in good standing to receive a Missouri license
within 30 days of applying

Download a copy of the report here.

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For several years now, my colleagues and I have been writing about the benefits of price transparency in healthcare, and the fierce opposition the idea has faced in Jefferson City. Naively, I assumed that informing patients of the cost of healthcare services before they were provided would be uncontroversial. After all, what other expensive goods or services do consumers purchase without knowing what they’ll pay beforehand? But after several price transparency bills received hearings last year the points of contention became a little clearer.

During public testimony on House Bill (HB) 1837 last year, the Missouri Hospital Association stated that complying with the bill’s price transparency requirements would be financially burdensome. This was confusing because HB 1837 simply added state-imposed penalties if hospitals didn’t comply with federal transparency requirements that are already on the books. As I’ve written previously, back in 2019, the Trump administration issued an executive order requiring hospitals to publish a list of standard charges for 300 common procedures in a user-friendly, shoppable display. This was a requirement that has since been extended to health plans and was kept in place throughout the entire Biden administration.

But as I’ve also explained at length, Missouri hospitals have been reluctant to comply (at least in spirit) with the federal requirements. In the years since, state legislators across the country have begun filing bills to encourage greater compliance. At first, the Missouri bills languished in committee without receiving public hearings. Then, last year, bills received hearings in both chambers of the legislature and were even voted out of committee. Unfortunately, this year, the subject didn’t receive a hearing in the House and wasn’t successfully voted out of committee in the Senate.

It’s hard to know what changed since last year that led to the policy losing support among Missouri’s legislators, but I think it’s safe to assume that hospitals still oppose the effort. Going into next year’s session, I’ll continue highlighting the benefits of price transparency and the importance of policymakers taking action to help rein in skyrocketing healthcare costs. While it may be true that price transparency isn’t a silver bullet for all that ails America’s broken healthcare system, it’s a step in the right direction that shouldn’t be delayed because certain providers claim they can’t afford it. Missouri patients can’t afford the wait.

The post A Step Backward for Transparency appeared first on Show-Me Institute.

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What’s Happening in Jefferson City?

Get the inside scoop on the Missouri legislative session and policies that could directly impact the lives of Missourians at the Show-Me Institute’s Insider’s Hour! Join CEO Brenda Talent, Director of State Budget and Fiscal Policy Elias Tsapelas, and Senior Fellow Patrick Tuohey for a discussion on tax and education policy and the latest efforts to improve government efficiency.

Wednesday, March 26

Carriage Club

5301 State Line Road

Kansas City, MO 64112

Doors open: 4:30 p.m.

Discussion and Q&A: 5:15 – 6:00 p.m.

Ticket Price: $20.00 (includes light snacks and beverages)

Get your Tickets Here

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Once again, several bills have been filed that would drastically improve Missouri’s telemedicine laws. As I’ve written before, Missouri was one of the best places in the country for telemedicine a few short years ago. Patients and providers were given a plethora of options for how they communicated, which greatly expanded access to health services across Missouri. But after the emergency declaration for COVID-19 ended, Missouri reinstated a variety of measures that needlessly restrict telemedicine access.

According to a report from the Cicero Institute, Missouri’s telemedicine laws are lacking in three key areas. First, our state is not what Cicero calls “modality neutral.” What this means is that Missouri’s telemedicine laws don’t allow for several modes of communication that have shown to be successful in other states. At least one bill filed this year attempts to move our laws closer to modality neutral by allowing telemedicine services to be provided via audio-only (not video) technologies. This is something mental health providers are very interested in.

Second, Missouri restricts telemedicine access across state lines. If you’re in St. Louis and need a doctor, why shouldn’t you be able to see a provider over telemedicine who practices in Illinois? With so many Missourians struggling to find the healthcare they need, expanding telemedicine access to any licensed provider who’s willing to treat Missourians seems like it should be a no-brainer.

Finally, Missouri makes it unnecessarily difficult for providers to write prescriptions for their patients, especially if they’ve only ever seen them over telemedicine. The process is even more cumbersome if the provider is an advanced practice registered nurse (ARPN). Clarifying the prescribing process and making it easier for APRNs to treat patients via telemedicine should be a benefit to both patients and providers. Fortunately, there are several bills filed this year that tackle these issues.

It’s time for Missouri’s elected officials to recognize that it’s not 2019 anymore. Telemedicine has come an incredibly long way in recent years, yet Missouri’s laws still treat the service as if things are the same as they were pre-COVID-19. Hopefully, this is the year Missouri’s policymakers take notice and take the actions necessary to expand telemedicine access.

The post On Hold for Telemedicine appeared first on Show-Me Institute.

Susan Pendergrass, Elias Tsapelas, and David Stokes join Zach Lawhorn to discuss the start of the 2025 Missouri legislative session. They cover budgetary reform, the need for a Missouri Taxpayer Bill of Rights, the creation of a recession preparedness fund, open enrollment policies, statewide school choice, improvements to Missouri’s school report cards, tax reform, telemedicine, healthcare regulations, and more.

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Produced by Show-Me Opportunity

The post The 2025 Missouri Legislative Session Begins appeared first on Show-Me Institute.

Susan Pendergrass speaks with Charles M. Silver, professor at the University of Texas at Austin School of Law, and David Hyman, professor at Georgetown Law, about their proposal for reforming Medicare by giving money directly to patients instead of providers. They explain how fraudulent practices like ‘upcoding’ are draining taxpayer dollars, driving up healthcare costs, and offer solutions to reduce fraud and improve efficiency.

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Produced by Show-Me Opportunity

The post How to Reduce Medicare Fraud with Charles M. Silver and David Hyman appeared first on Show-Me Institute.

According to the report, most hospitals in the St. Louis region are charging above what is considered a “fair price,” with BJC hospitals charging the most. To determine what was “fair,” the report used guidelines established by the National Alliance of Healthcare Purchaser Coalitions. The coalition determined that any rates below 200% of what the federal government reimburses for Medicare to be “fair.” This is a bar that not many hospitals in the area are able to clear (see graphic above).

Of course, not everyone pays the price that hospitals charge, and some hospitals in the region do offer lower or more “fair” prices. But what shouldn’t get lost in this discussion is that assembling a report like this that includes pricing data for every hospital in the St. Louis region would have been nearly impossible if not for the federal price transparency rules that went into effect in 2021.

I’ve written several times over the past year about the benefits of price transparency in the healthcare sector and suggested that Missouri should go further than the feds to maximize transparency. As of early 2023, fewer than half of Missouri’s hospitals were in full compliance with the federal transparency requirements years after the rules went into effect. Unfortunately, even fewer were posting their data in a format that was consumer friendly for patients to access and understand.

Even though the report’s authors were able to navigate their way through the federal data to generate findings for the St. Louis region, the process is still too difficult to expect the average Missouri patient to do the same. That’s why Missouri should, in addition to establishing its own price transparency requirements, follow the leads of many other states in creating its own web-based tool to make it easy for every patient to learn the prices of the care they’d like to receive prior to receiving it.

None of this is to say that simply requiring hospitals to publish their prices will be enough to immediately drive down costs, or entirely fix our broken healthcare system, but it’s an essential step toward making healthcare more consumer friendly.

Given that a coalition of businesses paid for this report, employers clearly want to be able to compare prices between providers, and that is something patients should be able to do as well. Hopefully, Missouri’s general assembly agrees, and lawmakers decide to make hospital price transparency a priority when they return to Jefferson City in 2025.

The post Transparency Yields Results appeared first on Show-Me Institute.

In short, the answer is Missouri’s Certificate of Need (CON) laws. These laws give the government power to manage competition in the healthcare industry by requiring permission before providers can open certain facilities, expand certain services they offer, or even install certain medical devices.

While being required to ask for governmental permission may sound bad enough, what makes CON laws even worse is that the healthcare facilities that are covered by the state’s CON laws help decide whether new competitors are allowed to enter their healthcare markets. It shouldn’t be surprising that when given the choice, incumbent businesses prefer less competition nearly every time. Competition means more choices—which in turn lead to lower prices. Artificially limiting supply, which CON laws do, has often been shown to result in higher prices.

So how does this apply to what’s happening in northern Missouri? According to a recent article in the Missouri Times, the Hannibal Regional Medical Center asked the state legislature this year for money to build a new radiation oncology unit in Kirksville, which is approximately 100 miles away from its Hannibal location. The Northeast Regional Medical Center (a hospital located in Kirksville) opposed the funding on the basis that the creation of a new medical campus would “cause a duplication in services that could produce a financial hardship for both hospitals.”

Apparently, this story goes even further back than this past legislative session. Two years ago, the Northeast Regional Medical Center submitted a CON application for permission to replace a linear accelerator (a machine used for radiology treatments) for its Kirksville hospital. In response, the Hannibal hospital filed an opposition under Missouri’s CON laws, effectively barring the hospital from purchasing the device that would allow it to offer better cancer treatments for its patients.

While it’s still too early to know what the result of the fight in northeast Missouri will be, it’s important to recognize what’s happening. As a result of the veto power afforded by Missouri’s CON laws, instead of Missourians having greater access to valuable cancer treatments in northeast Missouri, neither the hospital in Kirksville nor the one in Hannibal will be allowed to offer expanded services. In other words, Missouri patients lose.

Unfortunately, sometimes it takes a real-world example to illuminate the costs that Missouri’s CON laws impose on the state’s patients. It’s long past time for Missouri to repeal its CON. As long as the state’s incumbent healthcare providers are allowed to pick who their competitors are, Missouri patients will continue to suffer.

The post CON-sanity appeared first on Show-Me Institute.

It’s no secret that many Missourians struggle with healthcare access. For large parts of the state, there simply aren’t enough doctors. In those areas, nurses have often been tasked with filling the void. Advanced practice registered nurses (ARPNs), who are trained to treat many of the things people would normally visit the doctor for, are particularly well suited to help address doctor shortages. Unfortunately, the law that governs what nurses licensed in Missouri can do is unnecessarily restrictive.

My colleagues have written about the need to expand nurse’s scope of practice for years. In Missouri, APRNs are required to enter what are called collaborative practice agreements with doctors before they can treat any patients. These agreements can come with a variety of stipulations including the number of patients the APRN can see, how frequently they have to meet with the doctor and have their charts reviewed, and even mandating that they cannot be more than a certain number of miles away from the doctor to practice independently. In 2023, Missouri’s legislature scaled back some of the collaborative practice agreement requirements, including the ability to waive the geographic proximity requirements in some circumstances, but there’s still a long way to go to make Missouri’s licensing laws for nurses competitive with other states.

Most states don’t have any geographic proximity requirements, and it’s easy to see why. Imagine you’re a nurse who is treating patients outside of Cape Girardeau in southeast Missouri. There likely aren’t many doctors in the region. There are significantly more doctors around St. Louis, but they’d be too far away to comply with Missouri’s geographic proximity requirement.

In 2024, it’s hard to imagine how geographic proximity rules are still necessary. Maybe they made sense in 1970, but with today’s advancements in technology, it’s hard to see them as much more than an unnecessary hurdle that limits the number of healthcare providers across Missouri.

It’s time for Missouri’s elected officials to start taking the state’s healthcare access problems seriously because they aren’t going to fix themselves. Until action is taken, no one should be surprised when more and more nurses leave the state, further exacerbating Missouri’s shortage of healthcare providers.

The post What about the Nurses? appeared first on Show-Me Institute.

Several months ago, I wrote about the positive developments in the world of telemedicine, and the laws Missouri needs to change to bring these benefits to state residents. I was optimistic because several bills expanding the role of telemedicine received hearings near the start of this year’s legislative session, and there was little to no opposition voiced against the changes. Unfortunately, for reasons unknown to me, the telemedicine bills haven’t moved much since their public hearings.

What makes the lack of movement so surprising is that much of what the telemedicine bills do is restore benefits that Missourians enjoyed a few short years ago. As I’ve written before, during the state of emergency for the COVID-19 pandemic, Missouri was one of the national leaders on telemedicine. Because various laws and regulations were waived for emergency response, it was much easier for patients to access their healthcare providers virtually. In response, patients and providers alike grew to value the service—until the emergency ended, and state lawmakers allowed the prior telemedicine restrictions to return.

Two of the telemedicine bills being considered this year seem like no brainers. One expands the definition of “telehealth” to include audio-only technologies. Not everyone has access to the devices or internet required to transmit video, and not every medical service requires a visual examination. Many in the mental health field would like the ability to treat patients over the phone, but state law needs to change for that to be possible.

The second bill makes it easier to establish the physician–patient relationship virtually. Currently, there are concerns about doctors prescribing medications to patients who they’ve never seen in person. Clarifying the process that needs to be followed for safely prescribing medicine remotely seems like it would benefit both patients and providers.

Many Missourians are still struggling with healthcare access, due in large part to a shortage of providers, and telemedicine is one of the best ways to expand the available pool of providers. There are many providers already calling on our general assembly to allow them to see more Missouri patients. There’s still enough time for our lawmakers to act and finally answer the call for improving telemedicine access.

The post Don’t Drop the Call for Telemedicine appeared first on Show-Me Institute.

– The stadium tax debate in Kansas City
– The MetroLink expansion plan advances in St. Louis
– How to make it easier to access virtual health care in Missouri, and more

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The post KC Stadium Debate, MetroLink Expansion, and MO Loses the Top Spot appeared first on Show-Me Institute.

Missouri used to be a leader in telemedicine. During the pandemic, various rules and regulations that stifled telemedicine access were waived, and in their absence, the service grew immensely popular. But today, the waivers have long since expired, and telemedicine is once again too difficult to access. All that has to happen to return Missouri to the top of the national pack on telemedicine access is for the state’s legislature to act.

A little more than a month ago, the Cicero Institute put out a report grading each state on telemedicine access, and offered specific reforms that would help states move up the rankings. Cicero’s conclusions for Missouri were in line with what my colleagues and I have written before: it’s currently too difficult to get some prescriptions via telemedicine, and it should be easier for healthcare providers who aren’t specifically physicians in Missouri to care for Missourians via telemedicine.

Fortunately, there are several bills being considered in this legislative session that would significantly improve Missouri’s telemedicine laws. One approach would make it easier to establish the physician–patient relationship virtually. This would in turn make it easier for providers to prescribe medications to patients they’d never seen in person.

Another approach expands the definition of “telehealth services” to include audio-only technologies. Not everyone has access to a computer, phone, or internet that is capable of transmitting video. Further, not every medical service that could be provided virtually requires the provider to see the patient visually. For example, some psychologists may be able to safely care for patients over the phone.

Perhaps most importantly, both approaches are currently allowed by Medicare in some circumstances and were allowed in Missouri when the telemedicine waivers were in effect a few years ago. None of this is to say that there aren’t some situations where telemedicine treatment may not be appropriate, or that there may be times when an audio-only visit isn’t sufficient. But when telemedicine can safely and appropriately provide a service, Missourians ought to be able to choose that option. Missouri has several years of firsthand data showing that telemedicine access can be expanded without sacrificing patient safety, and more states are recognizing the benefits of the service.

Missouri’s lawmakers should act soon because the state’s healthcare access problem isn’t going away, and expanding telemedicine services is one of the best ways to address it.

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