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

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

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

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

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

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

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

The post A Curious Hospital Argument appeared first on Show-Me Institute.

It is pretty clear that the stimulus money turned Jeff City’s budget process into something a little more like Washington’s. That was probably unavoidable. When you tell legislators to spend a lot of money quickly, it is not going to be pretty. I don’t mean this as a criticism of the people in Jeff City, but I certainly look forward to the return of the old ways next year, when the General Assembly doesn’t have hundreds of millions to throw around. We had considered in the past doing a report on pork spending by the General Assembly, but we never did, because, frankly, there is not a lot of pork or earmarking in Jeff City. The stimulus money changed that, but hopefully only for one year. Former Sen. Wayne Goode put it well:

“The way it works in Missouri, is that you always need a majority vote somewhere — either in committee or on the floor. It doesn’t really work like it does in Congress. The process is tighter, more structured on the state level.”

I am excited to see these discussions taking place in the public, media, and campaign spheres. I applaud everyone participating in the conversation about how our governments decide to spend what they spend. The budget process in Missouri needs to remain much stricter than it is in D.C., and more of our elected officials in both parties need to swear off both earmarks (which I am defining as spending items put into place after the committee process has ended) and pork (which I am defining as using general tax dollars to benefit very limited interests).

The post Followup Articles on Pork ‘N Earmarks appeared first on Show-Me Institute.

(Link via Combest.)

The post And the Tables Get Turned, as We Link to Combest (Via Combest, of Course) appeared first on Show-Me Institute.

However, tough economic times are also just about the only time there is a real opportunity to reduce the number of government employees at all. When times are good and budgets fat, nobody says, “Hey, jobs are easy to come by; let’s fire the worst 10 percent of the public payroll and reduce both the size of government and the tax burden, right here and now!” Sometimes, you get a combination of factors that actually helps to make some reductions successful, as was the case for Gov. Blunt. He deserves great credit for that, even though it was nothing quite like the radical reduction in non-public-safety-related government employees that we need right now, in my opinion.

I don’t mean to single out Missouri state government employees, in contrast to local, state, or federal bureaucrats thoughout the county — which gets me to the point of this post. Today’s Wall Street Journal has a hysterical article about government workers in Belgium, and their abuse of sick leave. Read the whole thing.

It’s funny in many ways, but in a bigger way, it is just pathetic. This is what socialism (or quasi-socialism) does to people: It takes their initiative away, and any sense they might have of controlling their own destiny, all in the name of equality and fairness. So, you eventually get a nation of losers who can’t go to work because they are depressed that their girlfriend dumped them. No wonder InBev is actually run by Brazilians. …

The post Public Service in Belgium and Missouri appeared first on Show-Me Institute.

This unproductive exercise by our General Assembly, like all its activities, can be tracked on Policy Pulse. I found it by searching the keyword “christmas.”

The post Another Productive Legislative Session appeared first on Show-Me Institute.

The recent Reason Foundation report that ranked Missouri’s transportation system 13th in the nation still ranks us low (40th) for the quality of our bridges. Needless to say, it is imperative that the Safe & Sound program get moving to address this problem. I hope it happens via partnership with the private sector. It is going to have to get done somehow, though, and if that means using the transitional design-bid-build system paid for by bonds, then unfortunately, it may have to be done that way. (Assuming MoDOT has any bonding authority left.)

This situation really isn’t anybody’s fault. It’s well-known that commodity prices have increased, and credit market problems have been documented a time or two. So here’s hoping that the project gets going soon, to benefit all of us. I know MoDOT is doing all it can to move public-private partnerships forward, but I guess right now we just have to wait and hope it works.

The post Safe & Sound Bridge Program Still Stalled appeared first on Show-Me Institute.

Hulshof called the public private partnership idea (also known as some type of toll road) intriguing. “Imagine a parallel truck lane along Interstate 44 with just truck traffic that’s built with private funds,” Hulshof asked attendees during his hour session with the Chamber.

Here at the Show-Me Institute, we couldn’t be happier. David Stokes, an expert of sorts on public-private partnerships, has been advocating this type of solution for a long time, and recently gave a presentation in Mexico, Mo., discussing alternative ways to fund and fix the state’s roads. His policy study highlights the benefits of this type of partnership, and outlines the ways in which it can alleviate MoDOT’s budget problems. Although Hulshof stopped short of advocating public-private partnerships, it is good to hear that the idea is at least garnering some discussion.

The post Public-Private Partnerships, Please appeared first on Show-Me Institute.

Signals that public-private partnerships to manage Missouri roads give him "deep concerns," because of the potential for foreign ownership . . . Still, Jay Nixon leaves "everything on the table."

Having co-written an entire study of this subject, let me repeat that there is no "ownership" in a public-private partnership. The private partner leases an existing asset, or obtains the right to build and operate a future asset, but does not own it. The people of Missouri, through state government, would always own any infrastructure built or operated under PPPs.

As for the "foreign" part, I can’t fathom why this bothers so many people so much in these cases. It’s just a frickin’ road. (As an aside, I can understand why potential foreign ownership of Anheuser-Busch bothers people.) There are plenty of American campanies that can bid on these projects, and the leading international companies that do this type of transportation PPP are based in Australia and Spain. If we were to decide that we needed to really finish what we started in 1898 and return to war against Spain, like Rome v. Carthage, it’s not as if a Spanish company that built and operated a Missouri bridge could take the bridge and move it back to the Iberian Peninsula. This is foreign investment in America, that could potentially provide new transportation infrastructure only at a cost to people who choose to use the asset, and unlike the AB/InBev situation, no current jobs would be at stake. Why this upsets so many people is beyond me. …

The post A Post About Foreign Ownership That Has Nothing to Do With InBev! appeared first on Show-Me Institute.

P.S. — Thanks to Combest for the links, MOPNS for the videos, and all the newspapers for the articles!

P.P.S. — Just to be clear, the "bad" refers to biodiesel mandates, not KY3, the latter of which I’m a big fan of.

The post Sergio Leone Analyzes the Missouri Legislature and More! appeared first on Show-Me Institute.

We also did some great radio shows, and we’d like to thank Mark Kinsley and Kara Marxer at AM 1310 KZRG in Joplin for having me on his show along with Len Gilroy from Reason, and Dan Vaughn of KWTO 560 AM in Springfield for hosting us as well. We had an enjoyable, full-hour discussion with Mark and Kara on KZRG. To the many callers we had on KWTO with great questions: Thank you for your calls. To the couple of callers who accused us, more or less, of being part of a conspiracy to destroy our borders and create a North American Union: You are insane.

Finally, we were able to meet with some newspaper editors about the study, including Tony Messenger of the Springfield News-Leader, and we aprpeciated all of their time.

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The vetoed bill would have spent an estimated $200 million in excess of
Quality Jobs reauthorization, and there were unknown expenses
associated with the legislation that could cost Missourians even more, according to a release from the Governor’s office.

The extra tax credits included the “eminent domain train,” tax breaks for “phantom flights” to Europe and
a provision that would harm many existing Missouri employers by putting
them at a competitive disadvantage, as Show-Me Institute scholars have pointed out. It’s great that the governor sees the harm that some tax credits can do to the economy and the state treasury, but in hopes of calling a special session to slim down the bill, he still misses the point. Lowering taxes across the board and instituting more responsible tax policy is what wlil spur strong economic growth across the board.

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