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.

Unfortunately, that shocking finding is only one piece of the bad news included in the report. The same audit also revealed that thousands of people have remained enrolled on Missouri’s Medicaid program for up to ten years without the state checking whether they’re still eligible. Federal law requires annual eligibility reviews, but Missouri’s outdated IT systems somehow blocked the state’s Department of Social Services from checking the information of around 10,000 recipients for up to a decade. To be fair, some of these individuals might still qualify for benefits, but many probably do not. The point is that the state doesn’t know one way or the other.

The issues outlined in the audit are a perfect illustration of the many problems with Missouri’s Medicaid program that I’ve been writing about for years. This is an enormously expensive program that is riddled with waste and relies on outdated computer systems that are only making things worse.

Given Missouri’s budgetary uncertainty, it’s even more important that Medicaid benefits only go to people who are eligible for them. Eligibility reviews aren’t just bureaucratic hurdles with no purpose. Circumstances that make people eligible to receive welfare benefits change all the time. They find a job. They get married. They might even die. It’s essential that the state’s computer systems know this information as soon as possible to ensure that tax dollars aren’t being misspent.

Perhaps the worst part of the audit report is the recognition that these troubling findings aren’t new problems at all. Previous reports highlighted both the “death match” issue as well as the recipients who weren’t getting their eligibility checked. Some might remember that Medicaid eligibility redeterminations were a hot topic while they were paused during the COVID-19 pandemic, but it’s important to point out that these issues predate 2020, so we can’t just blame the pandemic.

This is another reason why some of the reforms I outlined from the One Big Beautiful Bill are so needed. Modernizing the state’s computer systems and improving eligibility verification so that errors like these don’t happen should be a top priority. Medicaid is far too expensive, and its costs are growing at far too an alarming rate for this level of waste to continue. What’s the point of having eligibility rules if they aren’t going to be enforced?

The post Checking Medicaid’s Pulse appeared first on Show-Me Institute.

At first glance, some might assume this drop is simply a byproduct of the state’s post-pandemic Medicaid redeterminations. But as I’ve written before, I fear that explanation doesn’t add up. Permanently disabled recipients aren’t people you expect to lose coverage once their eligibility is established, given that they’re unlikely to re-enter the workforce. Instead, the data and a new quote suggest a different story: PTD shifting.

As I’ve explained in more detail here, PTD shifting is the process where individuals who would normally enroll in Medicaid due to their disability instead enroll as a healthy adult in the Medicaid expansion population. Why would they do this? For recipients, it makes sense because gaining access to Medicaid coverage through expansion is a much easier process. They don’t need to prove their disability; they just need to be able to show that their income qualifies. And for the state, it makes even more sense because the federal government pays 90% of the healthcare costs of someone enrolled in Medicaid expansion but only about 65% for disabled individuals.

People with disabilities often have a variety of healthcare needs, which in turn means paying for their coverage is quite expensive. If some of these costs can be shifted to the federal government, it could yield huge savings for the state. The problem, of course, is that this is explicitly not allowed. Federal law requires that individuals enrolling in the Medicaid expansion population be “newly eligible” for services, meaning they couldn’t otherwise qualify for the non-expansion part of the program. While I have no proof this is what Missouri is doing, this is a trap I’ve feared our state could fall into since before we adopted Medicaid expansion.

My concern was reinforced in a recent article quoting Timothy McBride, the former chair of the MO HealthNet Oversight Committee. When talking about Missouri’s changing Medicaid enrollment, he stated:

Essentially, the recipients chose one door or another when choosing to enroll, and it’s a much easier path to sign up for the expansion than sign up through disability, since it can take one year or longer to become qualified for Medicaid as permanently disabled.

If his observation is true, and the federal government finds out that Missouri is effectively off-loading disabled enrollees into the Medicaid expansion population to save state money at the expense of federal taxpayers, the consequences could be severe. We’re talking hundreds of millions, if not billions of dollars, that could need to be repaid to the federal authorities.

Missouri’s lawmakers should take this warning seriously. The drop in PTD enrollment is no longer just an accounting curiosity—it’s a signal that our state may be running afoul of federal law. Ignoring this problem now could lead to both a fiscal and legal crisis later.

The post Medicaid in Trouble? appeared first on Show-Me Institute.

Several weeks ago I started my deep dive into the many healthcare reforms included in the One Big Beautiful Bill (OBBB), specifically focusing on Medicaid. This week, I’ll discuss three of the bill’s provisions that are intended to improve program integrity and reduce waste.

1. Increasing Redetermination Frequency: Instead of the current practice of checking each recipient’s eligibility once per year after they enroll in Medicaid coverage, the OBBB requires states to start doing so every six months. This provision isn’t solely about cutting costs, though Medicaid’s out of control spending should be reined in. It’s also about making sure that taxpayers are only covering the high cost of healthcare for those that really need it.
2. Reducing Retroactive Eligibility: In the past, Medicaid would cover medical bills for new recipients up to 90 days prior to their joining the program. The OBBB shortens this window to 30 days in an effort to incentivize those who are truly eligible for the program to maintain their enrollment or enroll while they are healthy. If successful, this provision should improve program integrity and help lower costs by treating recipients earlier, before their ailments become more costly.
3. Reversing Recent Actions: Toward the end of the Biden administration, several new Medicaid rules and regulations were promulgated that would significantly increase the program’s costs without much evidence of benefiting the health of recipients. The OBBB rolls back many of these rules, specifically one that would drastically raise the cost of nursing home care.

Taken together, the reforms contained in the OBBB represent a forward-thinking evolution of the Medicaid program. By focusing on clearer eligibility requirements, more practical retroactive coverage, and a scale back of burdensome regulations, these changes could strengthen Medicaid, making it more sustainable and better equipped to provide essential healthcare services for those who depend on it.

In my next blog post on the OBBB topic, I’ll dive into some of the healthcare reforms that will impact the entire sector, not just Medicaid.

The post More Big Beautiful Medicaid Changes appeared first on Show-Me Institute.

Susan Pendergrass is joined again by Elias Tsapelas, director of state budget and fiscal policy at the Show-Me Institute, for Part II of their conversation on the sweeping federal legislation known as the “One Big Beautiful Bill.” They unpack what the bill means for Missouri taxpayers, including changes to the standard deduction, tips and overtime, education savings accounts, and higher education policy. They also dig into the bill’s broader fiscal impact, from the growing federal deficit to the implementation challenges facing state governments.

Listen on Spotify

Listen on Apple Podcasts 

Listen on SoundCloud

Timestamps

00:00 Exploring the One Big Beautiful Bill
04:58 Tax Implications for Missourians
10:20 New Savings Accounts for Children
12:07 Changes in Higher Education
18:09 Federal Deficit and Debt Concerns

Listen to Part I Here

Episode Transcript: One Big Beautiful Bill Breakdown, Part II with Elias Tsapelas 

(Download Here)

Susan Pendergrass (00:00)
So I guess it turns out that the One Big Beautiful Bill was too big for us to talk about in one podcast. Elias, thanks for coming back. I realized after we stopped recording that there’s so much in there we didn’t even discuss. We barely even really got into it. So let’s talk about more of the One Big Beautiful Bill because it’s huge—hundreds, at least hundreds of pages long. And I can’t believe the people who voted on it read it through carefully. Now, as you’re going through it and learning things, I’d love for you to explain some of it to me.

Starting with—how does the no tax on tips and overtime work? I’ve heard a lot about this. I know it was a campaign promise. So is it true that if you’re waiting tables now and you get a few hundred bucks a night in tips, you don’t have to pay tax on it now?

Elias Tsapelas (00:51)
In theory, yes. Now, it’s not clear if it’s going to be something that impacts Missouri tax liability. It sort of impacts the federal tax code a little differently than the increased standard deduction and some of the other changes. So it might change some federal tax liability, but unless Missouri’s legislature changes some stuff, it’s not going to immediately impact Missouri taxes.

Susan Pendergrass (01:16)
But why—do you have to itemize to do it?

Elias Tsapelas (01:19)
No. Basically, Missouri has rolling conformity with the federal government. Missouri takes its gross income from the federal government, and the tax on tips and overtime piece isn’t going to impact the gross income calculation. So it may or may not become an issue in Missouri.

There’s also a big open question here about how much income tip workers are actually claiming, and how much that will change if you say it’s not taxed—because if they weren’t declaring it before, we don’t really know what the change will be.

Susan Pendergrass (02:05)
Yeah, so if you walk home with a wad of cash, you’re not necessarily going to add it up and write it down and claim it.

Elias Tsapelas (02:09)
It still might not be worth declaring all of it. But if Missouri brings it into the state income tax code, it could cost quite a bit of money. There are quite a few tax provisions here—especially on corporate tax—where we really don’t know how much it’s going to cost, but it’s probably going to be significant. There’s full expensing, depreciation, all kinds of things that are going to change both federal and Missouri tax liability. And then there was the standard deduction change we mentioned last time.

Susan Pendergrass (02:47)
Okay. So one thing that does impact Missourians is our tax credit scholarship program, where you can donate to a scholarship-granting organization like the Archdiocese of St. Louis, and they give out scholarships. Right now, you can get a Missouri state income tax credit for that—up to half of how much you owe the state. And now there’s a new program where you can take a federal credit of up to $1,700 for donating to these organizations.

You can’t get credits for both on the same donation, but you could donate up to half your tax liability and get the Missouri credit, and then separately donate $1,700 and get the federal credit. I know there’s a lot of rulemaking still to come, and I also know this program doesn’t start until January 2027. So it won’t affect people’s returns until April 2028. But—how do you think that’s going to work? Do you have any idea based on what you’ve read?

Elias Tsapelas (03:54)
Well, Missouri has to opt in first, right? I think the first step is getting the rules out and seeing which states opt in. I would assume Missouri will. The hope is that this becomes something more people understand and take advantage of.

In Missouri, even though we have tons of tax credits that people do use, it takes a while to build it into tax preparation tools like TurboTax. So you kind of have to know what’s going on. Maybe once the federal piece is in place—and there are also changes to the child tax credit—that’ll help.

Susan Pendergrass (04:24)
Spread the word. How’s that changing?

Elias Tsapelas (04:51)
Some of the temporary provisions from the 2017 bill are now made permanent. One of the things the One Big Beautiful Bill does is take temporary changes and make them permanent. We’ll see in a few years how many of these stay.

Susan Pendergrass (05:10)
So the child tax credit is now permanent?

Elias Tsapelas (05:13)
Yes. The changes made in 2017 are now permanent. It’s higher now, and there’s more of it that’s refundable. There’s still an income threshold to get the maximum amount. I think there are going to be a lot of tax credit changes. The bill also got rid of a lot of renewable tax credits. So there are a lot of changes to tax policy for both businesses and individuals. I think people will need to start thinking about their Missouri taxes a little differently, at least for the next few years.

Susan Pendergrass (05:59)
Another piece is the savings accounts for children—kind of like IRAs for kids. I’ve read that anyone born after January 1, 2024, or maybe anyone currently under age 18, is eligible. The IRS has to open the accounts, and you need a Social Security number. For kids born between January 1, 2024, and 2026, the government deposits the first $1,000.

Elias Tsapelas (06:52)
Yeah. What I was trying to figure out is how these differ from 529 plans. I think these will be harder to withdraw from. They do come with tax benefits for employers and others contributing, but taxes will have to be paid when the money comes out.

Susan Pendergrass (07:25)
Yes—capital gains. With 529s, the money goes in pre-tax and comes out tax-free if used for education. These accounts are less flexible. You can take money out for education, a house, or a business, but otherwise there’s an early withdrawal penalty plus capital gains. It feels gimmicky, since the government only deposits $1,000 until 2028 when the program expires.

But for many low-income kids, this could be their only savings. It’s meant to help those who wouldn’t have a 529. They were originally going to be called “Invest in America Accounts,” but they’re now called “Trump Accounts.”

Elias Tsapelas (08:50)
I’m curious to see if the $1,000 is the only money ever deposited into these accounts for most people. It may not be worth putting in more, but even with tax obligations, it’s still free money.

Susan Pendergrass (09:27)
Right. You turn 18 and have $10,000—it’s not nothing. But some worry that a future Democratic president with control of Congress could expand the program—like depositing $500 annually for anyone under 18. It starts to look like a form of universal basic income. But I suspect it’ll go away—it feels gimmicky.

Elias Tsapelas (10:16)
I’m curious if the government will make it easier to use for college or similar expenses. There are a lot of higher education changes in the bill too. As someone with student loans, I’m getting emails every day about them.

Susan Pendergrass (10:33)
Yeah. So tell me—what are the changes to higher ed?

Elias Tsapelas (10:43)
Well…

Susan Pendergrass (10:46)
I’ve heard it might hurt community colleges, but I don’t know why. Do you?

Elias Tsapelas (10:49)
There are new caps on loan amounts and some income-based repayment plans are being eliminated. For example, the SAVE repayment plan created by the Biden administration has been tied up in court. Interest collection is resuming, but payments aren’t due yet. Borrowers need to switch plans, but the old ones are gone. The new plan tries to prevent negative amortization, but it’s still unclear how well that will work.

Grad students will be able to borrow less. The government wants loans repaid more quickly. After five years of paused payments, there’s a huge administrative burden now to unwind all of this.

Susan Pendergrass (12:11)
I know—since the pandemic.

Elias Tsapelas (12:17)
Exactly. There’s going to be a big process for certifying income and re-establishing payments. Colleges are nervous—lower borrowing limits could change students’ decisions. And I don’t know if the federal government is prepared to roll all of this out smoothly. I still need to re-set my auto-withdrawal.

Susan Pendergrass (12:56)
Yeah. It feels like we have to wait six months or a year to see what actually happens. Even the work requirements for SNAP and Medicaid were pushed out beyond the midterms. So while people are celebrating or panicking, a lot of this is still TBD.

Elias Tsapelas (13:26)
Yeah. And when people talk about “cuts,” especially to Medicaid, they’re mostly referring to ten-year projections. But a lot of the actual cuts are back-loaded. The benefits hit first—then the cuts. And some of those cuts may never happen. There’s also a big expansion of health savings accounts. People with bronze marketplace plans or direct primary care arrangements could use them, but rules still need to be written.

Susan Pendergrass (14:38)
I read there might be fewer subsidies, maybe higher premiums?

Elias Tsapelas (14:44)
Depends. There’s going to be a bill later this year to debate extending the enhanced COVID-era subsidies. But those subsidies created a kind of shadow market—shady dealers signing people up for plans they didn’t even know they had. About 2 million people were enrolled in multiple subsidized marketplace plans last year. So now there’s a push to reintroduce some “skin in the game.” But we’ll see what ends up mattering or going into effect.

Susan Pendergrass (16:04)
And our senator is already trying to undo parts of the bill he voted for.

Elias Tsapelas (16:08)
Yeah, especially the provider tax piece. That would help rein in spending, but the cuts don’t go into effect for several years—giving time for backtracking. If none of the pay-fors happen and only the expensive parts do, this bill just becomes even more costly.

Susan Pendergrass (17:08)
What does this bill, even optimistically, do to the federal deficit?

Elias Tsapelas (17:15)
I still need to see estimates, but we’re looking at adding at least $4 trillion to the deficit. Possibly more, depending on what’s made permanent.

Susan Pendergrass (17:53)
I thought Republicans cared about balanced budgets. This feels irresponsible. What do you think?

Elias Tsapelas (18:08)
It’s a lot easier to say you’re for fiscal responsibility than to actually do it. With Medicaid, people say cut waste—but cutting funding means cutting payments to hospitals, doctors, and nurses. And those tax cuts were always going to be extended. Every person taking the standard deduction is getting a bigger deduction. That costs money.

The real long-term budget problems are in Medicare, Medicaid, and Social Security—none of which were addressed. So someone will have to get back to those eventually.

Susan Pendergrass (19:48)
Yeah. Social Security’s trust fund is going to run dry soon—maybe within 10 years. The numbers are so big, it starts to feel imaginary. People can’t wrap their heads around what it would take to have a balanced budget. Both parties just keep giving stuff away, so you’d be foolish to sit on the sidelines.

Elias Tsapelas (20:24)
Yeah—it’s just different groups they’re giving to. This bill was very expensive. And I think future efforts will make it even more so by eliminating what little cost savings exist.

Susan Pendergrass (21:03)
The SALT deduction, for example—capped at $10,000 in 2017, now up to $40,000. That’s a $30,000 swing. For Californians, that’s huge.

Elias Tsapelas (21:27)
Yeah, and the benefit mostly goes to higher-income people. Even in Missouri, some homeowners might benefit—but it mostly helps the coasts. And it gives high-tax states more room to raise taxes, since the federal deduction cushions the blow.

Susan Pendergrass (22:19)
Exactly. Crazy stuff. Well, I think we’ve covered a lot. I won’t make you come back again, but there’s so much detail—it’s not really what either side thinks it is.

Elias Tsapelas (22:45)
I agree. Especially with Medicaid and SNAP. And states will carry a big burden implementing this. Some will do it well, some will fight every piece. There’s going to be a lot of news as this all rolls out.

Susan Pendergrass (23:46)
Totally. Not directly related, but recently I’ve met people surprised by the real ID requirement. It’s been around for 10–15 years, and Missouri resisted it. Some states just don’t want to jump into federal programs.

Elias Tsapelas (24:04)
Yeah—I’ve seen signs about it at TSA forever. Always “effective in 3 months,” then postponed. But it finally happened.

Susan Pendergrass (24:11)
Right. And this summer, people are finally getting real IDs. Missouri was one of the last to implement it. So I don’t expect the state to jump on many of these changes either. But there’s still plenty of time to talk about it all again.

Elias Tsapelas (24:28)
Yes.

Produced by Show-Me Opportunity

The post One Big Beautiful Bill Breakdown, Part II with Elias Tsapelas appeared first on Show-Me Institute.

Back in May, when the concepts for the bill were still being discussed, I wrote about several of the proposals that I thought might be included. As a jumping-off point for a more in-depth discussion of the many reforms included in the OBBB, I thought it would be helpful to first compare what made it across the finish line to the ideas I discussed in my earlier post.

• Rein in financing gimmicks: As I’ve discussed at length, states have recently been drastically increasing their reliance on Medicaid provider taxes in response to rising healthcare costs. The OBBB freezes state provider tax rates where they are today, prohibits states from adopting new ones, and begins lowering the maximum allowable rate from 6% to 3.5% over a period of years (excluding those for nursing homes and intermediate care facilities). Missouri’s current rate for its hospital provider tax is 4.2%, so this change could have an effect on the state’s budget in several years once the OBBB is fully implemented.
• Work requirements: Instead of offering states the opportunity to try work requirements for their respective Medicaid programs, as has been proposed in the past, the OBBB goes one step further by requiring states that have adopted expansion to establish “community engagement requirements” for their able-bodied enrollees. These requirements largely exempt populations that aren’t considered working-age able-bodied adults, such as pregnant women and parents with dependents under the age of 14.
• Reduce “enhanced” federal match: Decreasing the federal government’s skewed payment structure for the Medicaid expansion population was one of my only expected reforms that didn’t make it across the finish line. While this change was excluded, the OBBB does eliminate the temporary increase in federal payment share that has existed for several years, which was an effort to entice states to adopt expansion. It also reduces the federal payment rate for states that cover illegal immigrants under their Medicaid programs.

All told, the OBBB includes at least a dozen additional healthcare changes that will impact Missouri in one way or another that I haven’t mentioned above. It’s also important to keep in mind that much of the OBBB will not go into effect immediately and will be implemented in phases over the next decade. For many of the changes included in the bill, it’s far too early to confidently predict the effect they may have on Missourians or the state’s budget.

Over the coming weeks and months, I’ll dive deeper into some of these provisions as more information related to Missouri comes to light. Time will tell whether Missouri’s government is ready or capable of successfully implementing the reforms on the horizon.

The post Medicaid Reform Incoming 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.

Listen on Spotify

Listen on Apple Podcasts 

Listen on SoundCloud

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.

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.

Listen on Spotify

Listen on Apple Podcasts 

Listen on SoundCloud

Produced by Show-Me Opportunity

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.

The post 2025 End of the Legislative Session Report appeared first on Show-Me Institute.

Congress is expected to debate a budget reconciliation package later this spring that primarily extends tax cuts passed in 2018 but also may include some federal Medicaid spending reforms. Here are a few ideas that have been discussed (keep in mind this is a non-exhaustive list, and all details are subject to change):

• Reduce “enhanced” federal match: As I explained in earlier parts of this series, the federal government is currently paying 90% of all Medicaid costs for able-bodied adults in the expansion population but only 65% for everyone else (aged, blind, disabled, etc.). Congress is considering reducing its expansion share to something closer to what is paid for the traditional population.
• Rein in financing gimmicks: In recent years, states have ramped up their use of Medicaid financing gimmicks to help pay for rising healthcare costs. Missouri is more reliant on provider taxes than almost any other state in the country. Congress is considering changing this arrangement to reduce the amount of money states can earn with these gimmicks.
• Work requirements: Show-Me Institute researchers have been writing about the potential of implementing Medicaid work requirements for more than a decade. But the federal government has rarely allowed them, and after a few court cases several years ago, it was determined that congressional action was needed for them to move forward. While it’s unclear who would be included in the requirements, how exactly they’d work, or whether they would be possible in Missouri, it’s certainly worth watching what Congress decides to do on this topic.

In the coming weeks and months, I’ll be keeping a close eye on whether Congress follows through with any of these reforms. It’s never too early to begin thinking about, if enacted, what they could mean for Missouri. There’s no doubt that the federal government reducing its spending on Medicaid could have an enormous impact on our state’s budget. But as with most things, the devil will be in the details. It will be particularly interesting to see if the federal government affords states any additional flexibility to deal with potential Medicaid changes.

In the next post of this series, I’ll discuss some of the steps Missouri’s lawmakers can take today to reform Medicaid and prepare for any opportunities in the future that could help get the state’s program back on a sustainable fiscal track.

The post Medicaid’s Check-Up: Part 5 appeared first on Show-Me Institute.

The post The Final Weeks of the 2025 Session appeared first on Show-Me Institute.

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

The post March 26: Insider’s Hour in Kansas City appeared first on Show-Me Institute.

As I’ve discussed in earlier parts of this series, the Medicaid program is financed as a partnership between states and the federal government. For traditional Medicaid recipients (parents, children, elderly, disabled, etc.), states pay approximately one third of all medical costs and the federal government picks up the remaining two thirds. But for Medicaid expansion enrollees (healthy adults), the federal government increases its share to 90%. And for both populations, this financing arrangement is open ended. This means that no matter what the total cost of care may be, if the recipient is eligible for Medicaid and is receiving a covered service, the federal government will pay the established share.

Now, let’s consider what these financing arrangements might incentivize, and how they could relate to the troubling outcomes described earlier in this series.

Several years ago, in my Medicaid primer, I dove into great detail explaining some of the problems with Medicaid’s open-ended funding structure. The federal government’s willingness to pay the majority of all Medicaid costs with no limits distorts the program’s true costs for states, which are ultimately responsible for administering the program. This arrangement not only fails to incentivize states to search for total cost savings but also effectively incentivizes them to shift costs to the federal government .

Perhaps the best example of this dubious incentive is Medicaid provider taxes (explained here). These “taxes” are a federally approved way for some healthcare providers to exploit Medicaid’s financing arrangement to generate additional federal reimbursement for themselves at “minimal” cost to state taxpayers. If it sounds too good to be true, that’s because it is. Lawmakers in states like Missouri have repeatedly been willing participants in this scheme, and our state has since become overly reliant on these provider taxes. What this means is that states have used these taxes to raise provider rates far beyond what state taxpayers could afford if the federal government ever decides to stop allowing the gimmick, which is a very real risk.

Another financing gimmick for states is the permanent total disability (PTD) shifting that I described in part three of this series. By agreeing to pay more for expansion enrollees (90% vs. 66%), along with the open-ended funding arrangement, the federal government has effectively incentivized states to enroll people into the expansion population that might have otherwise been eligible to enroll traditionally. For example, if Missouri’s Medicaid agency could enroll just 25,000 people with disabilities as expansion enrollees instead of traditional ones, according to my calculations (available upon request) state taxpayers could save upwards of $150 million per year. But as I’ve emphasized, the federal government has explicitly stated this behavior is not permitted. There’s no way to know for sure if Missouri is doing this until Missouri’s Medicaid program is audited, but I think there’s good reason to believe it’s happening. New York was caught engaging in this behavior not long ago.

Given all of this, it should be no surprise that Missouri’s Medicaid program is a bloated, inefficient mess. There’s optimism that in the coming months the federal government will begin pursuing Medicaid reforms that target its side of the financial partnership. In part five of this series, I’ll dive into some of the likely proposals.

The post Medicaid’s Checkup: Part 4 appeared first on Show-Me Institute.

In part two of this series, I briefly mentioned that in Missouri’s recent period of overwhelming Medicaid growth, the only eligibility category that had a reduction in enrollment is people with disabilities. Today, there are approximately 125,000 disabled Missourians enrolled in the Medicaid program, which is down 50,000 since its peak in 2023, down 25,000 since 2019, and is actually lower than at any point in the past 20 years (which is as far back as the data goes).

What could possibly explain this sudden shift? One explanation, as I referenced in part one, is that Missouri is still catching up on processing thousands of program eligibility redeterminations that were paused for several years during COVID-19. But the problem with that theory is that you wouldn’t expect many people with disabilities to lose Medicaid coverage once they qualify. They, unlike several other populations such as healthy adults or pregnant women, are less likely to only need coverage temporarily or just until they can get back to work. This is why I think it’s likely that disabled individuals are simply receiving their coverage through different means.

One way this could happen is through what I’ve called “PTD shifting,” which is something that I’ve been warning about since early 2020. PTD (permanent total disability) shifting was a key component of Medicaid expansion supporters’ claims that adopting the proposal would be costless for Missouri taxpayers. PTD shifting occurs when states exploit the way Medicaid is financed to shift a significant portion of disabled enrollees’ costs to the federal government. Given that people with disabilities often have a variety of complex medical issues, providing them health coverage can be very expensive, which in turn means that shifting these high costs to the federal government could save states a lot of money. The problem is that the federal government has explicitly stated numerous times that this practice is not allowed.

To be clear, I don’t have any definitive proof that Missouri’s Medicaid agency is doing anything wrong, but the latest program enrollment data should be raising some eyebrows. If my fears are confirmed, and Missouri is practicing PTD shifting, state taxpayers might soon be on the hook for an enormous Medicaid bill. This is because once the federal government discovers a state has been wrongfully receiving extra federal funds to support its Medicaid program, the feds could require state taxpayers to pay them back, which in this case could amount to hundreds of millions of dollars.

Needless to say, Missouri’s Medicaid program deserves a closer look from our state’s elected officials as soon as possible. The longer it takes to get to the bottom of what’s going on, the more difficult and expensive the fix is likely to be.

The post Medicaid’s Checkup: Part 3 appeared first on Show-Me Institute.

Missouri voters approved Medicaid expansion as a constitutional amendment in August of 2020, during the height of the COVID-19 pandemic. Due to legal challenges and various technical issues, expansion-eligible Missourians didn’t begin joining the program until October of 2021. As I stated in part one of this series, because of COVID’s impact on the program as well as the federal rules accompanying the increased funding, it’s been nearly impossible until now to fully analyze the rollout of Medicaid expansion.

Before voters weighed in on the measure, expansion supporters made several claims about how the policy would impact Missouri. At the time, I wrote repeatedly about three of their key claims with which I disagreed. First, they estimated that fewer than 250,000 people would enroll within the first year. Second, they said the expansion enrollees would be “newly eligible” for the program, which is something the federal government requires as a condition of receiving extra federal funding. And third, they said the expansion wouldn’t cost state taxpayers any money. In fact, they argued it would save money. Unfortunately, none of these projections came true.

As I also mentioned in part one of this series, prior to the pandemic, Missouri’s Medicaid enrollment was around 850,000, with about 520,000 of those being kids. Within one year of expansion being implemented (October 2022), Missouri’s Medicaid enrollment had ballooned to 1.4 million with 288,000 adults in the “newly eligible” expansion population. Today, with COVID safely in the state’s rearview mirror, program enrollment is still nearing 1.3 million total with 340,000 adults enrolled as a result of the expansion of eligibility requirements. The only Medicaid eligibility category that has seen a decline in recent years is that of people with disabilities—but that is a topic I’ll discuss in greater detail in the next post in this series.

To quickly summarize the impact of expansion thus far, enrollment has exceeded projections by around 35 percent, and current program costs are approximately 75 percent ($7.8 billion) higher than they were in 2019. The prediction that Medicaid expansion would be costless relied on Missouri being able to shift a significant portion of its costs to the federal government, which would in turn have saved state taxpayers money. Thus far, this has not been the case as Missouri taxpayers’ contribution to the state’s Medicaid program has grown by 74 percent ($1.6 billion) over the same period.

While hindsight is 20/20, it’s fair to say that the current problems with Missouri’s Medicaid program were predictable four years ago. Further, there’s no longer any reason to think today’s data represent anything other than the new normal for the program. It’s time to accept that Missouri voters were sold a bill of goods on Medicaid expansion, and it’s incumbent on our state’s elected officials to explore whatever actions are possible in the coming years to fix the problems that expansion has created.

The post Medicaid’s Checkup: Part 2 appeared first on Show-Me Institute.

First, here’s a quick recap of what’s happened with the program in recent years. In March of 2020, the COVID-19 global pandemic began, and the federal government declared a national state of emergency. Over the next several years, Medicaid’s enrollment boomed, and in response the federal government agreed to increase its share of funding for the program. But as is almost always the case, the additional federal money came with strings attached. Particularly, accepting the funds required Missouri’s Medicaid agency to stop checking whether program enrollees were eligible to receive services. This prohibition continued until the end of March 2023.

Additionally, during the pandemic period, Missouri voters approved a constitutional amendment that radically reshaped the state’s Medicaid program. The amendment expanded Medicaid by extending program eligibility to able-bodied Missourians making up to 138 percent of the federal poverty level. For a family of four, this figure represents yearly earnings of approximately $43,000. Unsurprisingly, this expansion has led to an enormous increase in program enrollment, and as with COVID relief funds, the federal government agreed to pay an increased share for those newly eligible to enroll.

Given these developments, it shouldn’t be surprising that Missouri’s Medicaid program looks much different today than it did four short years ago. Prior to the pandemic in 2019, Missouri’s Medicaid enrollment sat around 850,000, with about 520,000 of those enrolled being children. By 2023, total program enrollment had nearly doubled to 1.5 million, with approximately 740,000 of those being kids and 350,000 being adults who had enrolled as a result of the change in eligibility requirements. Today, according to the state’s most recent enrollment data, there are still nearly 1.3 million Missourians on the program, including 640,000 children and 340,000 “expansion” adults.

In terms of cost, the growth has been similarly shocking. In 2019, the program cost around $10.4 billion in total, with less than $2.2 billion coming from Missouri taxpayers via state income and sales taxes. In this year’s FY 2025 budget, Medicaid’s total cost has ballooned to an expected $18.2 billion, with $3.8 billion coming from state taxpayers. This represents a total increase of approximately 75%, and the growth of state taxpayer investment isn’t much lower at 74%.

In several upcoming blog posts, I’ll dive deeper into these numbers and explain why it’s important that our elected officials take action to rein in our Medicaid program sooner rather than later.

The post Medicaid’s Checkup: Part 1 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.

Listen on Apple Podcasts 

Listen on SoundCloud

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.

For years, I’ve written about how big of a problem the Medicaid program is for Missouri’s budget. More recently, I’ve discussed our state’s broader budgetary troubles. Medicaid has long been Missouri’s single largest budget item, and the size of the program continues to only increase. Since 2020, program enrollment has increased by more than 40%, with more than 1.4 million Missourians now on the rolls. Additionally, Medicaid’s total cost has grown by nearly 80% in just four years, from approximately $10.8 billion to $19 billion.

One saving grace over this period of skyrocketing growth is that state taxpayers have been spared from the brunt of the cost increases due to an enormous injection of federal funds. This doesn’t mean that state taxpayers aren’t paying more for Medicaid today than ever before. In fact, state spending on the program has increased by more than 70% since 2020. But during that time, Missouri also experienced a tremendous run of state revenue growth, which, taken together with the increased federal funding, has meant that Missouri’s lawmakers have staved off addressing the long-running Medicaid cost problem. Going into next year, things are going to change drastically.

The federal government has ended its “enhanced” pandemic-era match for Medicaid funding. Typically, the federal government pays roughly 65% of Medicaid enrollee’s healthcare bills, but from 2021 until very recently, Missouri has received an additional 5% for adopting Medicaid expansion, and an additional 6.2% to help cover the increased program costs from the pandemic. Missouri lawmakers will have to replace the extra federal funds with state tax dollars.

This means that, without action, state lawmakers should expect the general revenue cost of the Medicaid program to increase significantly next year, likely by at least several hundred million dollars. And given that recent reports suggest that state tax revenue growth is expected to remain relatively flat, it’s possible the cost of Medicaid might even increase by more than the state’s tax collections. If that were to happen, unless reforms were made to the Medicaid program, significant budget cuts to other state spending priorities such as education, roads, or public safety would be needed to finance Medicaid’s cost growth.

Unlike the COVID-19 pandemic, the coming budgetary shortfall is entirely predictable. The federal government gave states more than a year’s warning for when it would be reducing Medicaid payments, but Missouri’s elected officials have thus far chosen not to prepare for that reality. Successfully reforming Medicaid will take months to implement, which means that time is running out if policymakers want to make the changes necessary to steer our state clear of the budgetary shortfall that’s ahead. Let’s hope state lawmakers realize this sobering truth before it’s too late.

The post Beware the Medicaid Hole appeared first on Show-Me Institute.

For years, I’ve written about Missouri’s reliance on Medicaid “provider taxes” and their role in paying for government-funded health care services. As costs have increased, states have become increasingly reliant on these extra taxes, because they help prop up Medicaid spending by essentially shifting some of the share paid with state tax dollars to the federal government. While this may sound appealing, Missouri’s expected spending on Medicaid has never been higher (nearly $17 billion this year). Provider taxes are a big reason for that, as they make up more than a quarter of all nonfederal Medicaid spending.

As the graphic below shows, provider taxes aren’t like normal taxes, because they essentially allow different health care providers to exploit the way Medicaid is financed and extract additional federal dollars to help keep their Medicaid rates higher. Beneficiaries of these taxes, (i.e. hospitals, nursing homes, pharmacies, and others) claim they’re one of the only taxes where everyone wins. Well, everyone except for federal taxpayers—which of course includes Missouri state taxpayers as well.

Joe Biden, when he was Vice President, called provider taxes a “scam.” Essentially every audit, congressional report, or presidential administration that looks at these things concludes that they should be seriously scaled back or ended for good. And if that ever happens, Missouri is in serious trouble. Our state is one of the most heavily reliant on this financing gimmick in the country.

Now, I wouldn’t hold my breath for any major federal changes to provider taxes because that would require Congress to make a concerted effort at deficit reduction. But the Biden administration’s new effort to look a little more closely at how states are spending these extra federal dollars warrants greater attention. Since 2002, Missouri has allowed the state’s hospitals to essentially manage its provider tax revenues themselves, with little transparency regarding how or where those funds are being spent. It’s possible a little sunlight might help find some opportunities for savings, or at least give Missouri the kick it needs to start weaning itself off this unsustainable funding source.

If health care costs are going to continue their upward trajectory and Medicaid is going to remain the state’s largest budget item, efforts to rein in spending and root out waste will be necessary and should be encouraged. It’s long past time someone gave a closer look at the provider tax “scam.” I just hope Missouri is ready for what the increased scrutiny might expose.

The post A “Scheme” Worth Looking Into appeared first on Show-Me Institute.

Over the past few months, I’ve talked a lot about Missouri resuming its Medicaid eligibility redetermination process. In short, during a three-year pause on eligibility checks, Missouri experienced enormous Medicaid enrollment and cost growth. Today, more than 20% of all enrollees are likely ineligible for the program, either because they make too much money, have coverage from their employer, or have moved out of state. This means that Missouri is wasting upwards of $120 million each month footing the bill for health coverage for people who aren’t qualified to receive it.

Missouri’s Medicaid agency is now two months into processing redeterminations and enrollment has finally started dropping, albeit slowly. Recent reports from both national and local news outlets are attributing the enrollment decline to “paperwork issues.” In my opinion, this characterization is incredibly misleading.

States classify anyone who fails to respond to a renewal application as being removed from the program for “procedure reasons.” This is being referred to as “paperwork issues” by some. This is in contrast to the other classification of individuals removed from the program—those who were “determined ineligible.” The problem is that if the state never hears back from an enrollee after repeated attempts to confirm their eligibility, they can only be removed from the program for “procedure reasons” because there wasn’t enough information to determine their eligibility one way or another. Calling all failures to respond to the state Medicaid eligibility checks “paperwork issues” misses a key point.

Someone who knows they no longer qualify for coverage is incredibly unlikely to go through the effort of filling out and returning the Medicaid renewal application. For years, individuals on essentially every welfare program (including Medicaid, Supplemental Nutrition Assistance Program [food stamps], and Temporary Assistance for Needy Families) have been required to inform the state when something changes that would make them ineligible for services, but they rarely do. Recently, the Congressional Budget Office estimated that more than 5 million Medicaid enrollees nationally are currently enrolled in private health coverage, meaning states are losing billions providing coverage to individuals for whom it’s completely unnecessary.

Most Medicaid rules are biased toward recipients maintaining continuous coverage, which may sometimes be a good thing, but for many people, Medicaid is a resource they only need temporarily. No one is saying that eligible Medicaid enrollees should be removed from the program, but even if that does happen, they’re still effectively covered because the federal government will cover up to three prior months of health costs once they’re determined to be eligible again.

Removing Medicaid recipients who don’t provide evidence of eligibility is a necessary act of fiscal prudence—an act of prudence that, prior to three years ago, was standard, federally mandated operating procedure.

There’s no getting around the fact that more state tax dollars being spent on ineligible Medicaid enrollees means less money for other state spending priorities, such as education and infrastructure. If Missouri’s elected officials ever want a chance at reining in Medicaid’s runaway spending, scrutinizing the program’s rolls must remain part of the equation, and occasional drops in enrollment must be normalized as simply par for the course.

The post Problems with Paperwork appeared first on Show-Me Institute.