Missouri House Democrats fielded questions from reporters after the close of work for the week.
One of the legislature’s proposals that has become law will see Medicaid pay for a patient to visit a licensed chiropractor up to 20 times in a year. Backers say by giving Medicaid recipients more options for treating pain, fewer patients will risk becoming addicted to opioids, and the state will save money by getting away from other, more costly treatments.
House Bill 1516 allows licensed chiropractors to be reimbursed for treatment of conditions currently covered under the MO HealthNet program. Sponsor John Wiemann (R-O’Fallon) said such services are currently covered by most private insurance carriers and Medicaid parts B and C on a limited basis. He said more than half of the states in the nation allow Medicaid recipients to receive chiropractic services.
“Ultimately the goal of this legislation is to allow Medicaid recipients access to chiropractic health care providers at a lower cost and in many cases with better outcomes, and overall reduction in opioid abuse,” said Wiemann.
Wiemann said under HB 1516 Missouri will save money as MO Healthnet patients would turn less often to opioid prescriptions and to services from emergency rooms, hospitals, and physicians.
He said the bill is part of a shift happening across healthcare to offer patients more options for treating pain or other chronic conditions.
“Medicine’s moving in that direction, where it’s more collaborative in nature. It used to be very siloed – the doctors only did this, the nurses only did this … but interdisciplinary medicine is really kind of the wave of the future, and with technology and everything else it just makes sense to make sure we look at all of our options,” said Wiemann.
One of the St. Louis-area chiropractors who testified for HB 1516 when it was in a House committee is Doctor Ross Mattox. He said pain can stem from many different catalysts, and patients must be given more options to manage it. While the best answer isn’t always chiropractic care, he said those it can help should have the choice to use it.
“For that large number of people that come in and it is a musculoskeletal problem and it does respond to chiropractic care, you just got that person better without sending them down that really complicated pathway of lots of dollars in the form of referrals and advanced imaging, and the potential for addiction with opioids, surgeries, all that stuff,” said Mattox.
Doctor Quinn James also testified for the legislation. He said some of his patients are seeking chiropractic care after having used medication.
“When they start coming to us they’re able to start to slowly – through their primary [care provider] also – to be able to reduce the amount of medication that they’re taking, so we’re able to get them off of a lot of the opioid medications after we start treating them,” said Quinn. He said to date he’s only been able to offer that care to fully insured patients because Medicaid wouldn’t cover chiropractic care.
Wiemann said he expects more legislation to be filed in future sessions that would seek Medicaid coverage for other pain treatment options. Things like acupuncture and massage therapy could also be candidates for coverage, as a reflection of the shift in medicine to a more all-encompassing approach to treat patients’ pain.
“There’s no doubt in my mind that we will see future legislation that will be pushing for other types of therapies that can alleviate pain without the use of narcotics and opiates – therapies that are known and approved, not some untested and unproven therapies,” said Wiemann, who said he might even carry such bills. “I don’t have any that I’m looking at right now. I’m certainly open to looking at ones that are proven to save taxpayers money in addition to providing good medical outcomes.”
Wiemann noted that the Joint Commission on Accreditation of Healthcare Organizations, a nonprofit responsible for accrediting hospitals, began this year requiring hospitals seeking its accreditation to develop strategies to decrease opioid use and minimize related risks, and to offer patients at least one non-drug pain treatment option.
The House voted 137-4 to send HB 1516 to the governor’s office. Governor Mike Parson (R) signed it into law July 5. Its provisions become effective August 28.
A bipartisan, collaborative effort to extend Medicaid benefits for postpartum substance abuse treatment has been approved by the Missouri House.
House Bill 2280 extends MO HealthNet benefits for pregnant women who are receiving substance abuse treatment within 60 days of giving birth for up to 12 additional months. Any participating woman must follow the treatment in order to benefit.
Bill sponsor Marsha Haefner (R-St. Louis) said extended treatment has been proven necessary for success.
“Opioid and substance abuse during pregnancy is on the rise, with opioid use during pregnancy mirroring that of the general population,” said Haefner. “The current time offered for substance use disorder treatment, which is 60-days for these new moms, does not allow for enough treatment for most women to experience success with recovery. If a new mom is doing well then loses support and treatment for her abuse she will often relapse. Another risk of pulling treatment too soon is after a period of non-use, women experience an increased risk of overdosing because their tolerance is low.”
Stevens told lawmakers she was glad that the bill will cover a full range of treatments.
She said that one thing that came out of the committee hearing on the bill was that, “new moms need not just substance use disorder treatment. That we really need to have comprehensive, wrap-around services, and so I’m very pleased that this bill is full Medicaid coverage so that these new moms can get substance use disorder treatment, they can get mental health care, they can go see a primary doctor, and really support them that first year after giving birth.”
Representative Faith Walker commended the lawmakers involved in the legislation for the bipartisan effort that led to its passage.
“It is a very common sense, evidence-based approach to dealing with the opioid epidemic here in the State of Missouri and it will both save taxpayer dollars as well as save lives,” said Faith Walker. “I want to encourage the body to look at this effort that was put forward by all the bill sponsors moving forward for the rest of the session.”
Representative Keith Frederick (R-Rolla) said the bill represents something the legislature should do to help the most vulnerable in the state.
The bill’s projected cost is more than $4-million dollars through 2021, but Haefner noted it would save the state money that would have gone to caring for children who could go to state care if their mothers aren’t afforded treatment, and other cost avoidance. She said the budget the House is debating this week also includes money to pay for the projected costs to extend this coverage.
The bill has been sent to the Senate for its consideration. If it becomes law, the state will have to seek a waiver from the federal government to allow for the program to be created and implemented. Missouri would be the first state to seek such a waiver.
Haefner is hopeful the state could get an answer from the federal government by the beginning of 2019.
Legislators often say it is the one thing the General Assembly must do even if it does nothing else: pass a balanced state budget. This week the state House will take the latest step toward that end, when its members debate a budget proposal to be sent to the Senate for its consideration.
Representative Scott Fitzpatrick’s (R-Shell Knob) top priority when he was named House Budget Committee Chairman was to fully fund the formula for K-12 school funding. This budget plan would do that.
The bills would also not appropriate all of the money projected to be available, so that some will be left for expenses that are unforeseen or are greater than projected. In recent years, the legislature and governor had to take care of such expenses in a mid-fiscal year, or supplemental, budget.
“We agreed with the governor and the Senate that no less than $100-million should be set aside for a possible supplemental request,” said Fitzpatrick. “We also set another $100-million almost that is made up of Medicaid increases that the department requested that we did not fund, and we said, ‘Listen, we need you to do your best to hold down these expenses in Medicaid.”
The budget proposal would also maintain at their current level in-home Medicaid services to seniors and people with disabilities, assuming that a House bill to end a tax break for low-income seniors and disabled becomes law. The money that bill would make available would go to the in-home care program.
House Democrats don’t like basing the support of the in-home care program on eliminating that tax break. The lead Democrat on the House Budget Committee, Michael Butler, said his party came up with other options, and one of those would be to dip into that money set in reserve.
Democrats also want to preserve a change made to the budget proposal last week, when one of its members proposed shifting $6.85-million from the Attorney General’s Office to the state’s Public Defender System. The Attorney General’s Office didn’t have representative in the hearing, and the budget committee approved the change.
The Public Defender’s Office wants a boost in state funding to hire more counsel, and to deal with what it’s told lawmakers is an “overload” of cases. “We, along with quite a few Republicans, believe the public defender’s office is in dire need of those funds,” said Butler.
Fitzpatrick said there might be a statutory issue regarding that money beings shifted out of the Attorney General’s office.
Butler said another priority for his party is to make sure Lincoln University gets enough money to maintain its land grant status. He said the federal government has said Lincoln must have more matching funds in order to keep that status.
“We need to try to get as close to $6.1-million as possible. We are putting up $2.5-million this year and we’re very hopeful that is enough equity to the federal government,” said Butler. “Lincoln has for decades seen a disparity in funding. It has never met the land grant match. It has never been given proper funding.”
Butler said there is support from both parties for making sure Lincoln University keeps its land grant status.
The budget proposal would also fund a Medicaid asset limit increase, add money to the state’s senior centers, and restore some – but not all – cuts to higher education.
House passage would be just the latest stop for a Fiscal Year 2018 state budget. From the House it would go to the Senate, which will likely propose changes to the House’s plan. Once the two chambers agree on a budget, their proposal will go to Governor Greitens for his action.
State House members are doing groundwork on the Fiscal Year 2018 budget, ahead of the release by Governor Eric Greitens of his proposed spending plan. Mike Lear sat down with the ranking Democrat on the House Budget Committee, Michael Butler (St. Louis), to talk about his thoughts in facing what lawmakers say will be a difficult budget year.
ML: Let’s talk about the causes in a moment because I do want to get to that, but let’s start with where we are in the budget, and I think everybody agrees that there is a hole, that there is a – I don’t know if I’ve heard the word “crisis” yet – but it’s certainly a dire budget year. How do you deal with the situation that we’re in this year?
MB: “I think it’s first important to note how we got here. How we got to this budget hole and what I could call a budget ‘crisis’ is we are currently about $450-million dollars that we have to cut out of the budget for this year, and that is not because of the past governor and the past administration. It’s because of the legislature who controls the budget process. We’ve been hearing that the past administration is to blame but we have to include Republican majorities in both the House and Senate that actually create the budget.
“They have cut revenue for years and revenue is down. Expenses are barely up – are generally up for how they normally are, but because we aren’t taking in as much revenue because of plenty of tax cuts for the rich, and for businesses, and for specific special interests, are the reason why we don’t have enough money to provide services to people.
“We want to be a part of the solution. We’re going to help, but we’re in the minority. We didn’t cause the problem. We’ve spoken against the problem in many cases, and we can’t take the blame for something we did not do.”
ML: Since we’re talking about cause, we are going to hear a lot about Medicaid and the need to reform Medicaid, and that a lot of the costs [to the budget] are driven by Medicaid. What is the answer there? Is it a question of Medicaid reform?
MB: “Well, with a brand new governor who is just learning the budget and is late on giving us his idea of the budget – much later than any other governor in recent history – we have to remind him and other folks around the state how we got here. Part of how we got here, especially with Medicaid; when many members of the majority, the Republican party and the governor says that Medicaid spending is out of control, they made it out of control. They have cut Medicaid spending so much that it creates a system for poor people, Medicaid recipients, that can’t get to good care. They can’t get to their primary care doctors, which cost the system much less.
“In fact when primary care doctors have a choice to decide whether to take these patients, Medicaid patients, when they decide not to those folks are forced to take emergency room care which is much, much, much more expensive. And as we cut more – if we just say we’re going to cut more – we’re going to create more of that system. We’re going to create where folks either can’t get care, or can’t get care that the state can afford, and in the end folks are going to suffer, and many of the folks in poor rural areas that they represent.
“On the Democratic side we’re going to be sure we’re continuing to take care of people, putting people first and not special interests, and put people first, not just numbers on a budget. We believe that we should continue to make sure that folks can get good care and they can take care of their children as well, as Medicaid recipients.”
ML: We have a new administration in Washington D.C. Is now the time to pursue Medicaid expansion if this state is going to do it, when we could be seeing changes or a repeal of Obamacare?
MB: “Now is the time. The time was three years ago when the federal government was going to reimburse us at 100-percent. Now is still the time because we believe that President Obama, and the facts show that President Obama had it right.
“In states where Medicaid was expanded Obamacare premium healthcare costs have decreased. We’ve seen premium healthcare costs once again decrease in states that expanded Medicaid. We’ve heard the governor and the new federal administration, new president, say that healthcare premiums are increasing, but they’re only increasing in states that didn’t expand Medicaid.
“So, we’re going to talk a little bit more about expansion of Medicaid and we know that we have facts on our side, and we have statistics on our side that show that if we expand Medicaid not only will poor folks and working class folks benefit, so will people that have premium healthcare.”
ML: What is the path forward, then, on this budget year, when we do get the budget from Governor Greitens and start to go through that … as you said $450-million I think is the figure that’s going to have to come out of it. How do you approach this?
MB: “We can’t raise taxes. We can’t take more from Missourians. What we can do are find ways as we will continue to do where government can work better, where we can use more technology. We are unfortunately going to have to make tough cuts to services that may be a benefit to a small amount of people or a benefit to a small amount of special interests. Unfortunately that may be just an extra service that government has done.
“As Democrats we’re not trying to raise taxes. We don’t have the power to. But we want to make sure we’re finding waste, fraud, and abuse, and we’re finding if there’s money that we’re not using in the state budget, that we’re being good stewards of the people’s money.”
ML: Do you think there are a lot of places in the budget like that?
MB: “I think there are very few. Democrats have been working very hard over the years to fix those things in the budget already and we’ve been successful, and we’re going to continue to do that.”