Still Waiting on Price Transparency

Why is it so hard to figure out how much health care services are going to cost? It has been two years since the federal rule requiring that hospitals disclose their prices in a consumer-friendly format went into effect. Last year, it was reported that fewer than one in four hospitals were complying. Today, are consumers any better off?

Last month at a congressional hearing, Rep. Jason Smith stated that hospital compliance was still incredibly low, and only four out of 6,000 hospitals nationally have been fined. The American Hospital Association (AHA) claims compliance is much higher—around 70%—and the lack of fines is because many hospitals are working with the Centers for Medicare and Medicaid Services to become compliant as prescribed in the rule.

A little less than a year ago, my colleague checked nearly every hospital in the state for compliance, which was not an easy task. Compliance was at less than 30% statewide, and calling many of those websites “consumer-friendly” was a bit of a stretch. Now, taking the AHA’s claims about improvement with a grain of salt, I wanted to check some of Missouri’s hospital websites for myself.

The good news is that the interface on many of the websites appears to be better. I could more easily search for a few basic health care services, but I would still say the process was more difficult than it should be. Additionally, one of the most important benefits of price transparency is the ability to “shop” around; doing that is quite difficult because it requires navigating to each hospital’s website separately and trying to find the same procedure price bundles to compare.

If this is what compliance looks like, Missouri’s got a long way to go. Fortunately, some states across the country have already made a concerted effort to be compliant, as well as increasing costs for hospitals that remain noncompliant with federal transparency rules. States such as Florida and Maine have created their own online tools that make comparing prices and services between hospitals much easier. Some states, such as Colorado, take the push for price transparency a step further and prohibit health providers that refuse to disclose their prices from using the state court system to collect medical debt.

This past legislative session, there was some hope that Missouri would join the ranks of Colorado with a similar bill restricting providers that aren’t transparent from collecting medical debt, but the bill that was filed never received a hearing. As far as I know, there hasn’t been any movement on creating a state-sponsored price comparison tool.

Price transparency is not some cure-all that will fix everything that’s wrong with America’s health care system. But making it easier for patients to see what they’ll have to pay before they’re told to pay it would represent a significant step forward, and other states are making progress on this front while Missouri lags behind. Although there has been some progress since last year, there’s still plenty of room for improvement on the health care price transparency front in our state.

20 Missouri Districts Seek Exemption from the Missouri Assessment Program

At the most recent state board of education meeting, 20 school districts requested a federal waiver to be exempt from the Missouri Assessment Program (MAP). Per the federal “Every State Succeeds Act,” all state education agencies must implement a statewide assessment in mathematics and English/language arts (ELA) every year for grades 3–8 and once between grades 9–12. The federal government reviews and approves which tests can be used, and therefore, waiver requests for exemption must go to the federal government.

This waiver is being requested in partnership with the Department of Elementary and Secondary Education (DESE) in order to conduct a formal study (called the Demonstration Project) to determine if a new testing system should replace the existing MAP. If the exemption is granted, these districts would use their own test but would not administer the MAP. If the waiver is denied, these twenty districts would use their own test and also administer the MAP.

The MAP test is traditionally given to 3rd through 8th-grade students in Missouri at the end of the school year to evaluate their understanding in mathematics, English/language arts, and science. MAP testing also includes End of Course (EOC) tests for high school students who have completed four chosen subjects—Algebra I (or II if you took Algebra I in middle school), Government, Biology, and English II.

The Demonstration Project will use an adaptive testing system, which will test students and provide timely results three times per year. An adaptive test essentially learns who a test-taker is. As students miss questions, the prompts become easier, and vice versa. Through this process, a computer algorithm can learn a student’s skill set, provide a detailed report to the teacher, remember it, and use that student’s proficiency as a baseline for the next standardized test. In practice, a student will sit down at a computer for 90 minutes to take one 45-minute adaptive test on ELA and one 45-minute adaptive test on mathematics three times per year. Since this system is online and designed for quick feedback, a detailed breakdown of how each student performed will be provided to teachers and parents in order to help students improve throughout the year. The new state assessment will shift from a “lagging” indicator to a “leading indicator.” This system will require 280 less minutes of testing time and will cost $21.60 more per student annually.

Below are the 20 districts that are seeking exemption from the MAP:

  • Affton, Branson, Center, Confluence Academies, Fayette, Lebanon, Lee’s Summit, Lewis County, Liberty, Lindbergh, Lonedell, Mehlville, Neosho, Ozark, Parkway, Pattonville, Raymore-Peculiar, Ritenour, Ste. Genevieve, and Shell Knob

These 20 districts roughly represent the demographics of Missouri, with huge districts, rural districts, and a charter school (although low-income students are underrepresented).

The study was created because of doubts about the effectiveness of the MAP; as the Demonstration Project proposal states, “The MAP was never intended as a progress monitoring tool at the student level.” Since the MAP is administered at the end of the year, districts do not receive test results until fall of the following year. Districts claim that makes it very difficult to make adjustments and corrections within the school year if a student is struggling in a certain subject. They also claim that adaptive standardized testing throughout the year would allow teachers and administrators to make adjustments to help students before the next school year. (There are reasons to take these complaints from districts with a grain of salt, which I will get into in my next blog post.)

It will be interesting to see if this trial is successful. The desire to try something different than MAP (which traces its origins back to 1993) raises plenty of questions in itself, and I will discuss those issues also in my next post.

St. Louis Water, MAP Test Opt-out, and Medical Bills

David Stokes, Elias Tsapelas, and Avery Frank join Zach Lawhorn to discuss changes to St. Louis water rates, a new standardized test coming to Missouri schools, the challenges of increasing transparency in hospital pricing, and more.

Listen on Apple Podcasts 

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Produced by Show-Me Opportunity

Kansas City’s Courtship of the Royals Is Getting Awkward

Since their founding over 50 years ago, the Kansas City Royals have played their home games in Kansas City proper, but last month, the team announced they were considering a new stadium site north of the river and outside Kansas City’s city limits.

Kansas City Mayor Quentin Lucas declared that “Kansas City will not now engage in an intrastate regional race to the bottom that ultimately does little more than fleecing our taxpayers”—which is the right policy position to take! Meanwhile, Jackson County executive and former Royal Frank White echoed similar sentiments, suggesting county taxpayers deserved “loyalty” from the Royals.

In relationship terms, the snap response by Kansas City civic leaders had the tone of a bad breakup and a badly spurned partner. But that tone shifted in recent weeks, after the Royals’ management team confirmed that a second site was also under consideration just east of Kansas City’s downtown, within KC’s city limits.

For a moment, it seemed like a longshot attempt at making up was afoot. Yet, the Royals haven’t said much more to the public about the potential Kansas City plan . . . and apparently they haven’t said much to city leadership about it, either:

Kansas City Mayor Quinton Lucas said Friday the Kansas City Royals need to flesh out details for a downtown ballpark.

Lucas said to KMBC’s Micheal Mahoney on Friday that no one is hearing enough details about the Royals’ downtown plans.

“Here are the things that need to be shared with the citizens of Kansas City — and in my view — today,” Lucas said. “Why the need for a move? What’s the plan for, perhaps, wherever they’re going? And what’s the funding idea?”

Lucas said the longer those questions are unanswered, the more challenging it becomes for the plans to be successful.

The fact that Mayor Lucas suggests that the Royals should stay in Kauffman Stadium is itself somewhat jarring if you know what direction the team was heading in the last few years and what the mayor himself was supporting. From a story in November:

Kansas City, Missouri, Mayor Quinton Lucas predicts a new Royals stadium will be in and near downtown Kansas City. (emphasis mine)

Lucas spoke with reporters minutes after Royals owner John Sherman announced plans to move the team from Kauffman Stadium.

“The Royals will be somewhere, I’m predicting, between the river,” Lucas said. “North of 31st Street, but let’s be even clearer, probably north of the train tracks that are about at 22nd Street. And then probably somewhere between the state line and of course, I would say Woodland (Avenue).”

Take from that what you will. The Royals should pay for their own stadium wherever they go, and if they stay in the Truman Sports Complex, they should pay their way there, too. But for the last year, the Royals staying put has not been what the city has been preparing for. Quite the opposite, in fact.

But while city leaders have every right to ask what a professional sports team is going to want from the public, the public has every right to ask its elected officials what taxpayer resources they’re willing to give away. And that definitely applies here, where city and county representations in private to the team have, to date, not been made public.

Here are some questions Kansas City’s (and Jackson County’s) leaders need to answer about their plans for the stadium:

  • How much could subsidizing a new stadium for the Royals cost taxpayers?
  • Are the city and county committed to massive new spending on both the Kansas City Royals and the Kansas City Chiefs, or are there fiscal limitations that city and county leaders won’t violate?
  • What are those limitations?
  • What city services will be affected by these tax expenditure choices?
  • And why should Kansas City and Jackson County taxpayers continue to be on the hook for an amenity that the entire region enjoys?

To reiterate, no public money should go to a project like this, but if money is being spent on private sports teams, Kansas City and Jackson County taxpayers deserve respect and transparency. Taxpayer money spent on sports stadiums is a waste, and it also takes away from other vital public services such as policing

Maybe Kansas City and the Royals will kiss and make up, or maybe the team and the city are in an uncanny valley before an inevitable break up. But whether it’s a make up or a break up, billions of taxpayer dollars are at stake.

Update: Royals owner John Sherman told media today: “No one is waiting on us. We are the urging party.”

The Science of Reading in Missouri

Around the nation, students are struggling to read, and Missouri students are no different. In 2022, the National Assessment of Educational Progress found that only 30.29% and 28.48% of Missouri 4th graders and 8th graders were proficient or advanced in reading, respectively—slightly below the nationwide averages of 32% and 29%. If we want to improve these scores, further implementing the science of reading (phonics) could help, but many Missouri universities are not adequately instructing their teachers to use scientifically based reading methods according to the National Council on Teacher Quality (NCTQ).

Why should we care about phonics instruction? Because it works.

There are typically two views when discussing early reading instruction: emphasis on phonics instruction involving daily lessons, and a “balanced literacy” approach which puts an emphasis on understanding meaning (three-cueing method) with occasional phonics sprinkled in. Numerous studies from independent researchers, the National Literacy Institute, and the Congressional-sponsored National Reading Panel have indicated that systematic and explicit phonics instruction is more effective in helping students learn to read than non-systematic (balanced literacy) or no phonics instruction. These results can be seen in schools that implement it, such as in Richmond or in our own backyard at KIPP Victory Academy—whose recent, explicit emphasis on phonics helped it obtain the highest English/language arts growth rate in the entire state from 2018–2021.

So why aren’t all schools using this method? Many teachers believe this approach is incredibly boring and drives the love of reading out of children. Additionally, it is hard for teachers to learn and teach; Missouri’s new phonics training program (LETRS) in Missouri takes 160 hours to complete. Finally, universities are simply not instructing future teachers to use this method effectively, or even hardly at all.

The NCTQ conducted a survey to evaluate which universities are implementing scientifically based reading instruction into their curriculum for future teachers—and the results are concerning. Per the survey, only 25 percent of higher education institutions nationally adequately address all five core components (phonemic awareness, phonics, fluency, vocabulary, and comprehension) of reading instruction. Missouri is no better, as nearly half of our participating* universities received an F on the NCQT’s report.

*Central Methodist University (F), Hannibal-LaGrange University (F), Lincoln University (B), Lindenwood University (B), Lindenwood University Graduate (D), Missouri Southern State University (F), Missouri Western State University (D), Northwest Missouri State University (F), Southeast Missouri State (F), University of Central Missouri (F), University of Missouri-Kansas City (A), University of Missouri-St. Louis (C), University of Missouri-St. Louis Graduate (C); all other Missouri universities declined to participate

Many universities in Missouri seem to be shying away from a strategy that can help teachers become better reading instructors. The LETRS program was a good start, but that law is primarily about identifying and addressing problems in early childhood reading, along with some additional professional development opportunities for existing teachers. We need Missouri universities to get on board and give teachers all the tools they need to effectively teach kids how to read right from the start.

The System We Have Is Not the System We’ve Had

Make no mistake—enrollment in public education in Missouri is shrinking. Last year, we had about 863,000 students, down three percent from a high of 895,000 students in 2007. The National Center for Education Statistics projects that we will drop another seven percent by 2031, potentially falling below 800,000 students for the first time since the 1990s.

Sure, enrollment in many of our already small rural districts has declined so much that it raises the question of how the districts can continue to exist. But that’s not the whole story. Some of the “best” districts in St. Louis County have been experiencing steady enrollment declines. In 2017–18, the Clayton School District had almost 2,800 students. Last year, it had fewer than 2,400. A loss of four hundred students in a district of that size is significant. Similarly, Parkway C-2 has lost 1,000 students in the past few years, going from nearly 18,000 students in 2018–19 to fewer than 17,000. Rockwood, which had nearly 23,000 students a decade ago, now has just under 21,000, having lost 1,900 students from its high-water mark.

In fact, every district other than Ladue and Lindbergh has seen enrollment losses since 2010. But their gains of approximately 2,300 students don’t come close to offsetting the countywide loss of over 11,000. St. Louis County’s neighbor, St. Charles County, shows similar trends. The biggest districts are down by thousands of students.

So what does this mean? Even with no boundary changes, we will have excess capacity and too many teachers in most districts unless we make the region and the state more attractive to families. Districts can no longer rest on their laurels and assume their classrooms will be filled. Programs that allow parents to choose a school for each of their children and that allow districts to specialize in what they offer should be welcomed. Those hard district lines meant to keep students out may need to become more porous.

Public education in Missouri is no longer a system of more—more students, more teachers, more school buildings, more money. It’s a shrinking system, and that will bring difficult decisions. It’s time to start thinking about how we can design a smarter system to better serve our region.

Everyone Should Be Welcomed to the Party

The Jefferson County Public Water Supply District (JCPWS) has offered to purchase the shared municipal sewer system of Crystal City and Festus. I think this is great. I am a big supporter of service sharing in local government, and economies of scale can benefit everyone. But something is missing in this process.

What’s missing?

Other bidders.

That is not necessarily Crystal City or Festus’ fault. The bid by JCPWS was unsolicited (apparently) so we can’t say that other potential bidders such as Missouri-American Water or Liberty Utilities (both of whom have been active in sewer operations in Jefferson County in recent years) were intentionally excluded. However, moving forward without asking for more bids would be a serious violation of good government principles.

Both cities claim to be interested in keeping rates low:

“Both cities are concerned about maintaining the same level of service to residents and keeping the sewer fees as low as possible,” said Jason Eisenbeis, city administrator for Crystal City.

You know what other organization was interested in keeping rates low? The St. Louis water division, which has experienced a large number of water main breaks recently precisely because it kept rates low to appease voters. That didn’t give the water division enough money to properly maintain the system, and city residents are now paying the price for that, literally and figuratively.

Politicians keeping utility rates artificially low to benefit their voters is a terrible practice, and one of the primary reasons local utilities should be privatized in the first place.

It is great that Festus and Crystal City have received a bid for their sewers. As we know, the ability of small cities to operate utilities is getting harder and harder. As the municipal sewer commission explained in the article linked in the first paragraph:

The Festus-Crystal City Sewer Commission has been working toward improving the plant, but keeping up with federal sewage system regulations is a struggle, said Matt Unrein, the commission chair.

“We have been working hard these last few years to modernize the facility, but the regulations just keep changing,” he said.

Crystal City and Festus should open up their sewer system bid process to include all potential parties, not just some. Then, city officials can consider all options in a fully open and transparent process. If JCPWD has the best total bid, it can be selected by the cities. But anything less than an open process with multiple bidders would be a failure of local government.

Taking Stock of Inflation and the Recent Fed Pause

The Federal Reserve announced last week that it was pausing its campaign of inflation-fighting interest rate hikes, leaving the target for the federal funds rate in the 5–5.25% range. Does the pause mean mission accomplished and that is time to celebrate? Not so fast.

The good news: progress has been made. According to data released last week, the May consumer price index (CPI) inflation rate came in at 4%, which is far less than the 9% peak from mid-2022. However, now is not the time to move the goalposts. For years, the Federal Reserve has said its inflation target is 2%, and the economy is running at twice that rate. By contrast, before passage of the American Rescue Plan Act stimulus bill in early 2021, the economy had consistently remained at or below 2% inflation for the better part of a decade and had not hit 9% in over four decades. It turns out that former Treasury Secretary and National Economic Council Director Larry Summers was spot on in spring 2021 when he warned that “I think this is the least responsible macroeconomic policy we’ve had in the last 40 years.”

What is the reason for falling inflation? One explanation can immediately be ruled out. No, the Inflation Reduction Act (a misnomer if there ever was one) did not defeat inflation. For one thing, inflation was already falling before the bill passed in August 2022. Secondly, many of the provisions of the law have yet to go into effect. In fact, the treasury department and IRS just released guidance on some of the significant provisions of the Inflation Reduction Act just last week—nearly a full year after the bill’s passage.

The idea that the Inflation Reduction Act was going to reduce inflation has always been implausible, seeing as its tax hike provisions constrain supply, and its supposed deficit reduction does not begin to take place until 2028. The law increases deficits in the years 2024–2027. More artificially stimulated demand and constrained supply is not a recipe for bringing down inflation. If anything, the Congressional Budget Office is likely taking an overly sanguine view by saying that the law will have a negligible effect on inflation.

Instead, the Federal Reserve’s interest rate hikes and the expiration of American Rescue Plan Act provisions are likely the key factors behind the decline in inflation. Broadly speaking, there are essentially two ways to bring down inflation: reduce spending demand or expand the supply of goods and services. The second approach is preferable in that it simultaneously allows for lower inflation and higher economic growth, but the types of regulatory and tax policy changes needed to expand supply would require consensus in Congress and the White House abandoning the anti-growth policy agenda pushed by many progressives.

The first approach (reducing demand) is what the Federal Reserve has pursued. As the Fed raises rates, borrowing becomes costlier, which makes it less attractive for consumers to purchase things like houses, vehicles, and appliances using credit. Higher interest rates also make saving more attractive. The result: consumers pull back demand. Similarly, the expiration of stimulus from the American Rescue Plan Act reduces overheated demand while the expiration of anti-work provisions removes part of the straitjacket imposed on supply.

Is the falling inflation a surprise? Prognosticators have been all over the map with their inflation forecasts during the past two years, but it ought not to be surprising that inflation would come down once the Federal Reserve finally began to take action and hike rates. At the beginning of the year, soon after the release of the December 2022 inflation data, I published a blog post with a forecast of where inflation might be headed in the first half of 2023. In the spirit of accountability, the figure above shows my inflation projection through May 2023 compared to how inflation has actually played out in reality.

The red (projection) and blue (actual) curves track each other remarkably well in 2023. In fact, my earlier blog post stated “topline year-over-year inflation readings are set to fall rapidly over the next several months—possibly even falling below 4% by early summer.” As a reminder: the May inflation rate came in at exactly 4%. Although my projections were mildly on the optimistic side, they have mostly held up.

Does that mean inflation is no longer a problem? Quite the contrary. The figure below shows that higher prices have essentially been locked in. The Federal Reserve is not even attempting to bring prices down. It is just trying to moderate the future pace of price increases to historic norms. Unfortunately, purchasing power is still more than 3% lower than it was at the beginning of 2021, as shown in the figure below. Until wages start to consistently outpace prices, workers will continue to suffer from the lingering effects of the inflation surge. Here, too, the economy faces serious headwinds, considering that labor productivity is on the decline. But addressing the low productivity crisis is a topic for another day.

Where do we go from here? There is no such thing as almost landing an airplane. You either land it, or you crash. In this case, the Federal Reserve has one task: to land inflation at 2% sooner rather than later. The longer it takes to achieve the 2% target, the less inflation-fighting credibility the Fed will have as people start to accept a persistently higher inflation rate as normal, which will make the Fed’s job even more difficult.

While the headline inflation number is moving rapidly in the right direction (and will likely continue to do so at least for one more month), some of the components of inflation are still concerning. In particular, core inflation (which excludes food and energy) is falling much more slowly. The latest core inflation rate from the CPI report is 5.3%, which is only modest progress from the 5.6% rate from the start of the year. One glimmer of hope is that housing costs have been a significant recent driver of inflation, but the data are lagging. Because most people who rent sign one-year leases, large rent increases from several months ago when conditions were different in the rental market still affect current inflation readings. As tenants begin to roll over into new leases, the data should adjust and likely show a slowdown in rent increases.

The bottom line is that the inflation picture has improved, but we are arguably entering a murkier phase over the next several months. The Federal Reserve made clear in its statement regarding pausing rates that it was likely not done raising rates. Rather, the pause is an opportunity for more data to come in to guide future actions. But one thing is clear: the mission is not yet accomplished.

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