MCC Letter to the Missouri Senate - Concerns over SB 577, Missouri HealthNet

To: Missouri Senate

From: Missouri Catholic Conference

Re: SB 577 – Missouri Health Improvement Act

Date: April 2, 2007

Health care is not a commodity but ensuring access to health care is a personal and community-wide responsibility. In some significant ways, SB 577 seeks to implement this vision. The idea of ensuring that each person has a “health care home” could have great merit. So too, could the idea of assisting people in navigating the health care system by assigning Mo HealthNet participants to a “health care advocate.” In many respect, SB 577 contains the seed for what could be an improved health care system. However, the Missouri Catholic Conference has concerns about the bill as it is proposed for Senate debate.

In its most ideal form one can imagine the role of the “health care advocate” as being a person who solely represents the interests of the Mo HealthNet participants assigned to them. But the definition of the health care advocate found in the bill is very broad and could include, for example, an employee of a managed care company under contract to the state whose primary aim is to reduce health care costs. This would create a conflict of interest in which the so-called “health care advocate” is not truly the advocate for the participant but for the company. Clearly, the obligations of the health care advocate needs to be further defined by this legislation to ensure that the advocate truly is an advocate for the patient.

SB 577 fails to define the concept of a “health care home.” One would presume it is the patient’s primary care physician but this is never specified. Perhaps because of the lack of such a definition there are provisions in the bill where it appears that the “health care advocate” is assigned roles such as making health risk assessments that are the proper domain of physicians. The health care advocate may be a physician but could also be some other kind of health care professional with lesser credentials and reduced competency.

The MCC proposes the health care home be the patient’s primary care physician or a health clinic. Health risk assessments and regimens of health care maintenance should be recommended by the family physician or local clinic. The health care advocate’s role should be to represent the Mo HealthNet participant when there are conflicts with the individual’s physician, managed care company or others. The advocate should also assist the participant in carrying out their doctor’s orders concerning the use of prescribed medications and the adoption of healthy lifestyle changes relating to diet, exercise and similar matters.

SB 577 also suffers from a lack of clarity in regards to the system of rewarding healthy behavior and healthy lifestyle choices. The legislation never specifies what conduct will or will not be subject to incentives. Some future state administration could decide that the use of contraceptives or certain vaccinations will be mandated as a condition for earning points under this system. This kind of anti-family measure would offend the conscience of many Missourians who would be forced to subsidize conduct they consider immoral or unethical.

The point system raises other troubling ethical questions. Persons who fail to follow through on their health improvement participation agreement could be denied medically necessary services. It is one thing to award points that can be used for non-necessary services such as participation in a health club but quite another to deny medically necessary services because a person has failed to live up to their agreement. The legislation should make it clear that health improvement participation agreements cannot be used to deny medically necessary services.

In general, leaving the language of SB 577 so vague will only allow the state bureaucracy to increase and “fill in the gaps” with their own interpretations through state regulations, policies and other administrative decision-making that may not reflect legislative intent. In contrast, clear and definite guidance in state law will ensure that cost-savings are realized in a manner that is both ethical and responsive to the health care needs of Missouri’s most vulnerable citizens.

Instead of restoring the Medicaid cuts made in 2005 affecting working parents, SB 577 attempts to address their needs through provisions such as the premium offset program. This approach may enable some individuals with incomes above the federal poverty level to obtain health coverage but it doesn’t at all address the very poor who cannot afford to pay monthly health insurance premiums. Premium offset programs have had low participation rates in other states.

With regard to the working poor, over 74,000 parents lost coverage due to the 2005 cuts, none of whom had an annual income of over 75% of the federal poverty level. The 2005 cuts drove eligibility down to the lowest level allowed under federal law. A mother with two children can now make no more than $3,504 annually (20.4% of the federal poverty level) to remain eligible for health coverage. Fully restoring health coverage for this population admittedly would be expensive, costing roughly $115 million in state general revenue. However, this price tag could be significantly reduced if the legislature targeted for health coverage restoration those parents who are working. This could be done by disregarding more of the earned income of working parents. For example, by adopting a two-thirds income disregard approximately 37,000 parents would gain eligibility and the cost to the state would be about $58 million in general revenue, according to officials at the Missouri Department of Social Services. By expanding the earned income disregard available to allow working families to advance themselves out of poverty, the state of Missouri can demonstrate its respect for the dignity of work and workers.

About $300 million in state general revenue would be needed to fully restore the Medicaid cuts of 2005. Some lawmakers argue that the proposed state budget cannot accommodate this level of expenditure. But revenue is available, if not for fully restoring all of the Medicaid services cut in 2005, then for making significant restorations, such as restoring health coverage for working parents as described above. At the very least, the legislature should reject Governor Blunt’s proposed tax cut for wealthy seniors and for corporations that will cost the state of Missouri $132 million by the governor’s estimate, and use this revenue instead to restore Medicaid services. We also note that the governor budgets for a $200 million ending balance. It is inappropriate for the state to sacrifice pressing current needs simply in the name of fiscal securty. A modest portion of this ending balance, perhaps $40 million, can be shifted to restore Medicaid services. In general, the state has available between $150 to $200 million to restore Medicaid cuts made in 2005. We recommend the Missouri Senate reject proposals to cut taxes for wealthier seniors or for corporations and use excess state revenue available in this year’s state budget to restore health coverage to Missouri’s most vulnerable citizens.

Assigning the elderly and those with disabilities into managed care programs is touted as a cost-saving measure but research shows that savings are difficult to achieve for this population. A managed care program for the elderly and those with disabilities would require an extensive array of specialists providing care for a variety of medical conditions. Assembling such a provider network will be extremely challenging. Before adopting any statewide managed care program for the elderly and those with disabilities, a pilot project should be considered to determine if this approach addresses the unique needs of this medically fragile population.

We appreciate that there are different political philosophies concerning how to create accessible health care for Missouri citizens. Certainly, personal responsibility must be encouraged and private employers offered incentives to provide health benefits for their employees. However, the state of Missouri, acting on behalf of the people, has a moral obligation to ensure that all people have access to medically necessary services and preventative health care. Such a fiscal commitment is a test of our willingness to build a culture of life and compassion.

Although we appreciate the hard work of the sponsor and many others who have developed the ideas now embodied in SB 577, we cannot support the legislation in its present form. Either the legislation should be amended in a significant manner by the Missouri Senate or it should be put aside for further work and action next year. In this regard, we suggest the sunset on the Medicaid program be extended so lawmakers can consider this very complicated issue in a deliberate manner. Overhauling our state’s health care system is serious business with great potential to either assist or harm our most vulnerable citizens. Let us take the time to do it right.