Rising electricity demand and retiring coal plants put Missouri at risk of higher prices and unreliable power.

The Solution

Create a nuclear advisory council and explore consumer-regulated electricity (CRE) to position Missouri for next-generation nuclear power.

Key Facts

• Nuclear energy is reliable, powerful, and clean.
• 71% of Americans agree that the United States should “definitely build more nuclear power plants in the future,” up from 47% in 1998.
• Businesses rank energy availability among their top priorities in site-selection decisions.

The Growing Demand for Nuclear Energy

Nuclear power has played a pivotal role in meeting historical energy needs. Today, electricity demand is growing and the primary drivers are well known: data centers, artificial intelligence, and industrial manufacturing.

Amid rising demand, nuclear energy has emerged as a rare point of political agreement, as both the Biden and Trump administrations have endorsed more nuclear power—with the latter issuing pivotal executive orders to bring long-needed reform. Outside the Oval Office, the ADVANCE Act (for nuclear energy) flew through the Senate (88-2) and the House (393-13) before being signed by President Biden.

Missouri has long possessed unique strengths to lead in nuclear energy, but now, national-level momentum and reform have created new opportunities.

A Missouri Nuclear Advisory Council

Tennessee’s nuclear advisory council has seen tremendous success since its creation by executive order in 2023.

Missouri could form a similar council to unite the state’s brightest minds in the energy sector to identify regulatory, workforce, and educational challenges and strengths while highlighting opportunities such as coal-to-nuclear transitions—at no cost to taxpayers.

The council could reduce risk and uncertainty for both international and domestic developers by providing centralized and accessible information, as well as clearly signaling the state’s resolve and intentions to be a dedicated partner in nuclear development.

Bringing the Free Market into Energy

Consumer-regulated electricity (CRE) is an emerging policy that would allow off-grid electricity providers to build their own power plants and transmission lines to serve new customers faster and with less red tape. To be free from Missouri Public Service Commission (MPSC) regulations, CRE providers would need to be unconnected to the regular grid and only serve new, large industrial and commercial customers. These providers would still be subject to federal regulation from the Nuclear Regulatory Commission and other federal agencies.

CRE could help Missouri meet demand growth, attract investment by companies quickly seeking stable energy, lower costs for utilities and ratepayers, and spur innovation.

To allow CRE, Missouri would need to modify state statute such that new off-grid electricity providers are not subject to monopoly regulation (assuming they are unconnected to existing infrastructure, do not cross state lines, and only serve large customers). New Hampshire moved forward with CRE in 2025. Missouri could do so as well.

Policy Recommendations

• Establish a Missouri Nuclear Advisory Council.
• Through CRE, inject market forces into the energy sector by exempting off-grid electricity providers from MPSC monopoly regulation.

The post Nuclear Energy 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.

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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.

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

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

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Timestamps

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Recently, the White House unveiled its detailed framework for deploying nuclear energy, which emphasized the need for nuclear power in America’s future. This plan included an ambitious target to triple U.S. nuclear capacity by 2050. While this specific plan may not survive the transition, the sentiment is likely to endure.

Bipartisan Support for Nuclear

Both sides of the aisle recognize the potential in an American nuclear resurgence, albeit with different motivations. Part of the reason the Biden administration supports nuclear energy is because of climate change. Ambitious emissions goals are difficult to achieve without nuclear energy. The previously mentioned report argues:

Expanding domestic nuclear energy production has a key role to play in helping to avoid the worst impacts of climate change by enabling the nation to achieve a net-zero greenhouse gas emission economy no later than 2050. Nuclear power delivers safe, clean, reliable, and affordable electricity.

The Trump administration’s support hinges largely on reliability, capacity, and energy security. Members of the first Trump administration have advocated for keeping plants open, investing in SMRs (small modular nuclear reactors), and continuing to modernize the Nuclear Regulatory Commission. The president-elect recently affirmed this stance:

Starting on day one, I will approve new drilling, new pipelines, new refineries, new power plants, new reactors and we will slash the red tape. We will get the job done. We will create more electricity, also for these new industries that can only function with massive electricity.

Outside of the Oval Office, another notable example of nuclear momentum is the passage of the ADVANCE Act, which is designed to spur advanced nuclear construction and streamline regulations. This bill flew through Congress with an 88–2 vote in the Senate and a 393–13 vote in the House of Representatives before being signed by the president.

Bipartisan Action in Missouri

Nuclear energy is unique in that it is safe, powerful, and environmentally friendly. It is the most reliable energy source, and some claim it produces the lowest amount of greenhouse gas emissions over the lifecycle of the power plant. Public awareness of these benefits is increasing, as Bisconti Research found that favorability for nuclear energy increased from 49 percent in 1983 to 77 percent in 2024 among the U.S. public.

In the past, nuclear energy may have been viewed through a partisan lens, but today, it represents a solution to address some of our nation’s key concerns. This upcoming legislative session, lawmakers in Jefferson City should come together to craft meaningful policy that will help bring more nuclear power to the Show-Me State.

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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.

In response, I weighed in on the details of this policy. In particular, I noted the lack of trust in free-market innovation, even though the EV industry was kickstarted and fueled by market forces and ingenuity.

The Missouri legislature appears to be fearful of NEVI opening a Pandora’s Box of EV expansion mandates and is considering ways to curtail it in the upcoming session. House Bill (HB) 184  was recently pre-filed and would create protections for small-business owners subject to onerous local government mandates like the NEVI Deployment Plan. Under this bill, any political subdivision that adopts a rule requiring the installation of charging stations at any non-fueling business would be required to pay all costs associated with the installation, maintenance, and operation.

While I appreciate this pre-filed bill defending the rights of some small business owners, why are fueling-businesses excluded from its protection? If a fueling business does not have charging stations, that probably signals it does not have market demand for that service. Only 1% of cars on the road are electric, and in many rural counties you could probably count the number of EV’s in the community on one hand. When it makes economic sense for fueling businesses to install charging stations, they will, and they shouldn’t be forced to do so prematurely.

Unfortunately, a law protecting against overreaching EV mandates only treats a symptom of the disease—the mandates shouldn’t be happening in the first place. The EV market has been rapidly innovating through fierce competition and expanding due to increased consumer interest. As it grows, restaurants, hotels, fueling-stations, landlords, and other businesses will face economic decisions about whether to add charging stations to their premises to attract consumers. A barbershop with limited parking may not want to build an EV station, but for a landlord, an EV station could be beneficial for luring tenants. Why is the government getting involved when market forces are driving progress on their own? By the time government-mandated projects like NEVI are actually completed, who’s to say that those charging stations will even be up to date?

These inefficient mandates are unlikely even to significantly increase the convenience and allure of EVs. In a study published by Plug-in America, only 9% of all EV owners said charging stations being too far apart was a major difficulty, and 7% said that there were not enough charging stations at each location. In addition, 60% of EV owners charge their vehicle at home daily. What problem is the government trying to solve if current EV owners are comfortable with the availability of chargers and most of them charge their cars at home?

Hopefully, protections can be put in place for business owners when inefficient EV expansion projects are implemented, but I hope HB 184 will not even need to be invoked.

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The proposed route received some tweaks earlier this month, and now is set to run from Natural Bridge Road at Grand Boulevard in north city down Jefferson Avenue past the National Geospatial-Intelligence Agency (NGA) headquarters and the site of the new MLS stadium. This new plan has an estimated price tag of between $600 and $800 million and would be financed primarily through federal funds. However, like the ill-advised KC Streetcar expansion, expanding MetroLink would be a waste.

The first and most obvious problem with the proposal is ridership. The project is touting the ability to connect impoverished areas of North Saint Louis with centers of commerce in places such as downtown and the Central West End. However, project leaders have yet to put out research supporting this claim. Considering that fewer and fewer people are commuting downtown for work, there are reasons to be skeptical of this assertion.

As a longtime Saint Louis sports fan, I understand that MetroLink can be a convenient way to get downtown and avoid the stress and costs of parking. However, building an additional stop and line to service the new MLS stadium is completely unnecessary, considering its proximity to Union Station­­­–it is only 0.2 miles away, or a five-minute walk. Instead of changing lines to access the dedicated stadium stop, soccer fans taking the train downtown would be better off exiting at Union Station and making the short walk over.

As with the KC Streetcar expansion I wrote about in a recent blog post, spending hundreds of millions of dollars on a questionable MetroLink expansion comes at the expense of bus systems.  Saint Louis Metro has been forced to cut lines amid staffing shortages, an issue which is predicted to persist into next year. Metro Bus is the primary means of transportation for roughly 22,000 St. Louis commuters, compared to only 4,000 commuters who primarily use MetroLink.

If St. Louis wishes to use federal money to improve public transit, it should improve the bus system and invest in more efficient types of public transportation, like Bus Rapid Transit (BRT). Unfortunately, policymakers’ tendency to chase shiny objects will likely leave Saint Louis with a defunct trolley, an oversized light rail system, and thousands of unhappy bus riders.

The post Even with an Updated Route, MetroLink Expansion is a Waste appeared first on Show-Me Institute.

Inflation has reared its ugly head again—hitting a 30-year high of 6.2 percent, which is more than triple the Federal Reserve’s definition of stable prices. Unfortunately, the wayward policies that have contributed to soaring prices, pervasive shortages, and sputtering growth are not going away. In fact, they are poised to get a whole lot worse.

President Biden signed the first of two giant spending bills into law on Nov. 15. That was the $1 trillion “Infrastructure Investment and Jobs Act.” The second bill is the administration’s proposed Build Back Better Act, passed by the U.S. House of Representatives a few days later and now pending before the Senate.

Taken together, we are looking at a potential tsunami of bad policymaking. Let us count the ways the two pieces of legislation threaten our nation’s freedom and prosperity:

#1. The infrastructure act is only partially about infrastructure as most people think of it. For example, the law spends only $110 billion on fixing roads and bridges—barely putting a dent in the maintenance backlog—while Amtrak alone will get 60 percent as much as all of America’s bridges and roads combined. Yes, that Amtrak—the one that has consistently run operating losses almost every year for the past 50 years. Tens of billions of additional dollars will go into public transportation even though only five percent of Americans rely on public transit in commuting to work.

#2. Also under the infrastructure act, the government says it will make “the largest investment in clean energy transmission and grid in American history,” and it calls for “building thousands of miles of new resilient transmission lines to facilitate the expansion of renewables and clean energy.” Wind and solar have been lavishly supported for decades, but still only account for 11 percent of U.S. electrical power generation, and their actual role is much less than that because they are intermittent. Does anyone seriously think they can come anywhere close to replacing gas and coal as the primary source of 60 percent of electrical power generation and be equally cheap, reliable, and easy to use?

#3. Then, too, as part of the green energy component of the “infrastructure” plan, the federal government will mastermind the building of a network of 500,000 electric vehicle charging stations, thereby not only putting taxpayer money at risk, but also putting the federal government in the position of picking winners and losers among America’s small-town communities through its choice of where to put those stations. The survival of local communities may soon depend increasingly on Washington, D.C.’s whims.

#4. The proposed Build Back Better Act would permanently and dramatically expand the welfare state and abolish work requirements as a condition for receiving aid. There would be some “free money” for taxpayers at all levels of income. The wealthy would get theirs in the form of expanded state and local tax (aka SALT) deductibility. The top current deduction of $10,000 isn’t much for a top-one-percenter living in an expensive house in a spendthrift, high-tax state like California or New York. Build Back Better includes an eightfold expansion of the maximum SALT deduction to $80,000. The typical taxpayer would get no benefit, while top earners would receive an average windfall of nearly $23,000. The Build Back Better Act would also permanently enshrine the Biden administration’s reimagined Child Care Tax Credit, which would allow a family to receive thousands of dollars a year ($3,600 per child under age 6 and $3,000 per child at 17 and under) in government cash with zero earned income and no expectation whatsoever of anyone having to seek a job.

#5. Adjusted for a lot of gimmickry, a close reading of the bill shows that it would result in nearly three trillion dollars in cumulative budget deficits over the next decade. Claims that the bill will not add a dime to deficits and debt are entirely spurious.

To sum up, what we have here is an overarching vision for transforming America. It would concentrate more decision-making power in the hands of the central government. And it would turn what has been a society of producers, workers, and investors into a society of people and institutions (including unions, businesses, schools, and an enlarged army of social workers and activists) whose livelihoods depend on what government gives them.

The post Commentary: A Tsunami of Bad Policy appeared first on Show-Me Institute.

The CARES Act made several large changes to the unemployment insurance system. These changes were intended to be temporary and preserve family and small business finances during the period of greatest uncertainty. Specifically, the CARES Act extended the duration of unemployment benefits, added a $600 weekly supplement to the usual state benefit amount, expanded eligibility to gig workers and many others traditionally excluded from the unemployment insurance system, and introduced other modifications such as the waiving of job search requirements to account for the unique circumstances of the pandemic. At the end of 2020, the federal government extended into March the supplemental benefit amount at a lower level of $300, and President Biden’s American Rescue Plan extended these enhanced benefits further until September 2021.

These changes to the unemployment system have undoubtedly had major effects on individuals and the economy. The additional $600 was certainly beneficial for the financial situation of the unemployed; researchers have found that additional benefits from the CARES Act resulted in 76 percent of unemployed people earning more than their previous wages on unemployment between April and July. In Missouri, the median replacement rate of UI benefits (including the $600) to lost wage earnings was 154 percent, meaning those on unemployment made 54 percent more than their lost wages. Even with these extra earnings, research has found that unemployment benefits did not harm job growth in spring and summer 2020 when lockdown restrictions made job search very difficult.

However, conditions have changed. Most businesses are open, vaccines are available to those who want them, and the unemployment rate has fallen from 14.8 percent to 6.1 percent. Are these extra unemployment benefits still necessary? Job openings hit a preliminary record high in March and anecdotally, many businesses are struggling to find workers. It’s certainly possible that the additional $300 and the long extension to September are causing people to push back their job search and extend their time receiving UI. Jobs will likely be even more abundant by the time benefits expire, thereby reducing the risk of a delayed job search.

It seems that the job market (and therefore our economic recovery) is being helped by vaccine access and business re-openings and hurt by extended unemployment benefits. However, we may be able to see the light at the end of this UI tunnel. Governor Parson announced that Missouri would end participation in the federal pandemic unemployment programs on June 12th, saying that these benefits were always meant to be temporary and it’s time to get people back to work. The federal government is also taking steps to return to pre-pandemic UI rules. Lawmakers seem to recognize that getting people back to work is a priority and enhanced UI benefits may not have been moving us toward that goal. Hopefully, these changes will help us continue to recover quickly.

The post How Are We Recovering? (Part 3) appeared first on Show-Me Institute.

As things currently stand, the American Rescue Plan promises jobless workers $300 per week on top of the usual wage replacement rate of just under 50% all the way into September. For most of the workers who are receiving nearly the same or more to remain jobless, it is understandable that they might be reluctant to accept a pay cut just to go back to work. For small businesses struggling to reopen, these unemployment benefits represent anywhere from a short-term headache to an existential threat. Many of them operate on small profit margins and cannot afford to compete with the artificial compensation offered by a federal government with a nearly endless capacity to borrow. Tacitly acknowledging the role of unemployment benefits in the lackluster jobs numbers, President Biden is now exhorting workers that “if you’re receiving unemployment benefits and you’re offered a suitable job, you can’t refuse that job and just keep getting unemployment benefits.” He has also directed the Department of Labor to work with states to reinstate job search requirements, which in their current form are mostly window dressing that cannot effectively monitor or induce search effort. Instead of trying to fill the leaky bucket caused by bad policy, the federal government ought to plug the hole and stop erecting hurdles to small business hiring and reopening.

In Missouri, the economy sports what sounds like a healthy 4.2% unemployment rate, but here, too, many Missourians have exited the labor force, and there are over 114,000 fewer people working relative to back in February 2020. Missouri’s recently announced termination of enhanced unemployment benefits is one positive step toward addressing this jobs shortfall and returning its economy to pre-pandemic strength.

The post How to Put Missouri on a Faster Path to Recovery appeared first on Show-Me Institute.

America’s infrastructure needs are genuine and significant. Investment in basic infrastructure (power, transportation, water supply, etc.) has failed or barely kept up with depreciation, leaving the country with an aging infrastructure stock with dwindling years of remaining service life. Moreover, although the United States spends roughly the same on infrastructure as it did in 1956 in inflation-adjusted per capita terms, it gets less bang for the buck today. In particular, the cost per mile of interstate construction has more than tripled in inflation-adjusted terms since the 1960s.

This combination of flat spending and rising costs means less actual new infrastructure. Worse yet, costs vary widely across states. From 1956 to 1993, high-cost states spent more than $8.8 million more per mile of interstate than low-cost states, and $3.3 million of this differential is due to factors under policymaker control. Thus, rather than measuring the ambition of a bill by the sticker shock of its price tag, a superior metric is to evaluate the quantity and quality of infrastructure it is likely to produce and what spillovers it will generate for economic productivity. On both counts, the Biden Administration’s plan falls far short.

First, the composition of spending in the bill appears not to have gone through any credible cost–benefit analysis to determine where best to allocate scarce (or not so scarce, given the size of the bill) dollars. For example, the American Society of Civil Engineers reports that 20 percent of the more than 4 million miles of roads in the United States are in poor condition; the same report estimates a nearly $800 billion backlog of maintenance and repair needs. Why, then, does only 5 percent of the bill (see Figure 1) go to roads and bridges, only promising to fix 20,000 miles worth of road? Moreover, why spend nearly the same amount on public transportation even though only 5 percent of people rely on it to get to work? The bill also includes Medicaid expansion of home and community-based services (HCBS) masquerading as “infrastructure.” The administration every right to make its case for a “care economy” agenda, but simply calling it infrastructure to piggyback off of the popularity of spending on roads and bridges does not make it so.

Figure 1

Secondly, and more egregiously, the American Jobs Plan’s prevailing wage, project labor agreement, and PRO Act provisions are a huge giveaway to unions that would likely raise costs, reduce growth, tilt the playing field, and overturn the will of voters in states that passed right-to-work laws to safeguard worker freedoms. The practical effect of these measures will be to reduce the number of infrastructure projects that can get completed for a given amount of spending and to needlessly harm economic performance through the elimination of worker freedom protections.

Lastly, the Biden plan partly finances the eye-popping $2.3 trillion price tag by raising the corporate income tax, thereby undermining the very competitiveness that infrastructure investment is supposed to enhance. Even the administration tacitly admits the harm such a tax hike will cause for the economy, offering only to beg other countries to raise their own taxes to prevent them from attracting companies looking for friendlier business environments in what the Biden administration misleadingly calls a “race to the bottom.” It’s hard to imagine any countries taking us up on the offer. In all fairness, the American Jobs Plan does promise workers whose jobs are displaced counseling and case management services, though many will unsurprisingly prefer to keep their job instead.

In sum, America’s infrastructure could use a jolt of investment, but the spending priorities in the bill are off target and in many cases unrelated to true infrastructure. The bill is littered with union giveaways that will raise costs and reduce the quantity of new infrastructure that could otherwise be produced, and the promised corporate tax hikes counteract the same economic growth that infrastructure spending aims to ignite. But it’s not too late. The Biden administration should learn from previous mistakes, when the Obama stimulus failed to improve the nation’s highways, and instead refocus on a pro-growth and fiscally responsible approach to solving America’s pressing infrastructure needs.

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