April 11, 2008

The Senate Appropriations Committee completed its work this week "marking up" the budget bills to talk to the Senate floor.

The Senate will take the budget to the floor next week and then send the approved version back to the House where the House Budget and Senate Appropriations Committees will name conferees to work out the differences in the week after next week.

Legislation that creates a new type of project under the enhanced enterprise zone tax benefit act known as mega–projects and opens the door for Bombardier, a Montreal–based company, to build a $375 million airplane assembly plant at the Kansas City International Airport was debated at length this week. Bombardier is considering KCI as a potential site for the plant, which would employ approximately 2,100 workers paying an average annual wage of $55,000. Senate Bill 1234 clarifies the procedures of how the Department of Economic Development can offer state assistance through existing programs including the Enhanced Enterprise Zone and Quality Jobs Act programs, which provide incentives to companies such as Bombardier.

The House Special Committee on Utilities heard legislation that would help Aquila avoid tearing down its power plant, which was built without the proper permits from local zoning officials. Rep. Ed Emery introduced the bill, allows the PSC to approve the construction of a gas plant, power plant, or water or sewer system after construction is completed. Current law requires the PSC to determine that the construction is in the public interest before construction begins. The PSC approved the Aquila plant last year, but the Missouri Court of Appeals ruled that the PSC lacked authority to approve a plant that had already been built. Aquila has been ordered to tear the plant down and this legislation will allow Aquila to keep it in operation. Rep. Jake Zimmerman who is listed as a sponsor of the bill, told committee members that he was misled by Aquila's lobbyist about what the bill actually did. Rep. Emery planned to hear and vote on his bill in the same day, but legislators on the committee objected and wanted more time for consideration, however, the bill was voted out of committee the next day.

As we get later in session tensions and tempers flair, but this week tempers were at an all time high when legislators had to be separated as an argument went a little too far in the back of the House chambers Thursday. The quarrel stemmed over debate from the day before that became heated with accusations from Rep. Skaggs claiming legislation for school vouchers was only being debated because of political contributions from powerful financial backers who have contributed hundreds of thousands of dollars through political action committees or directly to legislators who support school voucher legislation. The legislation was debated for several hours Wednesday, but after an amendment was added to strip the voucher language it was laid over. House Majority Leader Steve Tilley started session Thursday morning advising legislators with accusations of unethical behavior to go before the House Ethics Committee instead of bringing it up on the house floor. After Tilley's announcement, he and Rep. Skaggs began arguing in the back of the chamber and had to be separated by staff and other legislators. Shortly after, another argument started between House Majority Whip Brian Nieves and Rep. Skaggs and had to be broken up after Skaggs "tapped or lightly slapped" Nieves on the check. The bill, which is a priority of Speaker Rod Jetton, would have raised the minimum starting teaching salary by more than 20% and set the state's first–ever minimum salary standards for more experienced teachers. It would have also offered bonuses to teachers based on performance or a willingness to work in poor districts. But, a provision allowing state tax credits to offset donations to charities, which in turn would provide scholarships so autistic or disabled children could go to private or other public schools, better known as school vouchers, was stripped from the bill by a vote of 80–58 vote Wednesday night before it was laid over on the informal calendar. Tilley supported the tax–credit provision and told the press that without that provision the bill will not be brought back up for debate. The voucher issue, which allows students to transfer from public schools to private schools at taxpayer expense, has been battled for years and was defeated last year as well. Public school officials say allowing such proposals would drain money from their districts and question whether private schools could provide the same quality or accountability as public schools.

The Governor appointed Chuck Pryor to the Board of Probation and Parole. Pryor was appointed as Deputy Chief of Staff of Legislation and Policy for the Governor in October 2006 and also served as his legislative liaison during his term in the Office of Secretary of State. Prior to that Pryor represented the 116th District from 1993–2000.

News this week includes:

Senate Insure Missouri Proposal Advances

Within limits set by legislative appropriations, state plan amendments and federal Medicaid waivers, Senate Bill 1283 would authorize a new "Insure Missouri" coverage system for individuals ages 19–65 who have been uninsured for at least six months. Coverage could be extended to those with incomes of as much as 225 percent of the federal poverty level, if legislators appropriate funding. It also contains several other components unrelated to Insure Missouri. Senate Bill 1283 passed out committee yesterday. The full Senate is expected to debate the bill next week.

The bill proposes a broader entitlement to coverage than a similar proposal by Representative Doug Ervin in House Bill 2413. It would increase eligibility for custodial parents with incomes of as much as 100 percent of the FPL and would give enrollees a larger preventive care benefit. The new version of the Senate Committee Substitute has been modified to show that custodial parents under 100 percent of the FPL are a separate state plan amendment group. In addition, the bill would make more limited changes to state laws governing the state high–risk pool.

The following are some other noteworthy items outlined in the legislation.

• Creates a Missouri Health Cabinet consisting of six members, including the governor, education commissioner and the directors of the Departments of Health and Senior Services, Mental Health, Social Services, and Insurance, Financial Institutions and Professional Registration.
• Certain adverse events would be reported to a federally–qualified patient safety organization. The new language is the same language contained in Senate Committee Substitute for Senate Bill 916.
• The sponsor has revamped language allowing the MO HealthNet Division to define and deny payment for certain preventable errors beginning October 1, 2009. The provision now allows the newly created Professional Services Payment Committee to review and make recommendations to the MO HealthNet Division regarding standards and policies for denying payment to a health care provider for treatment costs associated with preventable errors. Members of the Professional Services Payment Committee have not yet been appointed by the governor.
• "Cost transparency" language considered unworkable has been removed. The sponsor replaced the language with transparency provisions based on similar language from Florida law.
• Requires coverage under MO HealthNet for prescribed medically necessary therapy services, including physical, occupational and speech therapy.
• Promotes telehealth and free clinic services.
• Implements an emergency room diversion project.
• Creates a tobacco use, prevention and cessation fund.

The Senate Committee has kept funding alive by placing 25 million in GR for funding the Insure Missouri program.

This funding item raises the amount from the $14 million designated by the House.

This move adds flexibility for the House and Senate conferees.

This money will be held in budget negotiations until a statutory bill is passed. Consequently, Senator Dempsey and Representatives Ervin and Schaaf are working on HB 2413 and HB 2398.

Senate Advances Forensic Exam Bill

Legislation modifying provisions on forensic examinations of sexual assault victims was approved by the Missouri Senate this week. Senate Bill 1159 codifies an executive order from Gov. Matt Blunt by moving payment to medical providers for forensic exams of sexual assault victims from the Missouri Department of Health and Senior Services to the Missouri Department of Public Safety. Medical providers are reimbursed for the exam's cost with money from the newly created "Sexual Offense Forensic Examination Compensation Fund." The fund consists of money from the crime victims' compensation fund, general revenue and federal funds.

In addition, if the medical provider reasonably believes the sexual offender is the victim's parent or guardian and the victim is under 18, the medical provider is only required to provide written notice of the exam to the nonoffending parent or guardian.

Pharmaceutical Bills Advance

Senate Bill 1068 was advanced by House Committee this week. It establishes the Pharmacy Rebates Fund for the purpose of depositing any revenues received by the state from pharmaceutical manufacturer rebates as required by state or federal law for use in the MO HealthNet pharmacy program.

House Bill 1332 was advanced by the Missouri House this week and would establish guidelines that any entity auditing a pharmacy must follow. Entities conducting an audit must develop an appeals process under which a pharmacy can appeal an unfavorable audit report. This requirement would not apply to any investigative audits involving fraud, willful misrepresentation, or abuse.

Immigration

The House perfected legislation intended to help law enforcement deal with illegal immigrants. The bill requires the Highway Patrol to undergo federal immigration law training. The provision is subject to appropriations, but the Senate eliminated their funding this week. The Governor recommended $253,050 in this year's budget for 75 officers to be trained to use federal immigration databases and enforce immigration laws. Most of the debate centered on the provision that would outlaw sanctuary cities by prohibiting local governments from adopting policies limiting the ability of local officials to communicate with the federal government about potential immigration violations. Other provisions of would require citizens detained for crimes to be checked for immigration status; require a commercial driver's license examination to be given in English; and create penalties for anyone who assists an illegal alien in obtaining a driver's license. Illegal immigration legislation was one of the Governor's priorities for this year. He has been working with U.S. Immigration and Customs Enforcement (ICE) for authority under the Immigration and Nationality Act for Missouri law enforcement officers to enforce immigration laws as federally deputized ICE agents. He also directed agencies to conduct random inspections and perform "Compliance by Written Demand" action for all entities receiving state tax credits to verify proof of legal status for all workers. The Missouri Housing Development Commission has implemented a strict workforce eligibility policy which includes sanctions of up to a lifetime ban of contractors and developers who knowingly employ illegal immigrants in violation of federal law.

Panel Hears Bills Denying Public Benefits To Illegal Immigrants

House Bill 1736 was heard in a House Committee this week and establishes the Missouri Illegal Immigration Relief Act and prohibits providing any federal, state or local benefits to a person who is unlawfully present in the United States. It also requires all employers to register with and utilize the federal E–Verify Program operated by the U.S. Dept. of Homeland Security. Additionally, it authorizes all political subdivisions to enact laws prohibiting or restricting employment of unauthorized aliens and the harboring of illegal aliens.

House Bill 2320 was also heard in a House Committee and would prohibit business entities and employers from employing, recruiting, or hiring illegal aliens to perform work in Missouri. It also requires participation in a federal work authorization program which enables employers to electronically verify employment eligibility. Violations result in suspension of business licenses.

Quality of Care Standardization

Senate Bill 1272 would standardize the quality of care data that health insurers can require health care providers to submit as a condition of payment. The legislation is designed to ensure that health care providers don't spend so much time and effort collecting and reporting data for health insurers that they have little time to work on improving quality of care.

Insurers would be able to require the quality of care indicators that the federal Centers for Medicare and Medicaid Services (CMS) has chosen for public disclosure in comparative format. The bill also includes language to ensure that the quality of care information being given to the public is fair and accurate and data standards are open to public review. Those who would sell or otherwise furnish quality of care data would need to make their data standards available for review and give providers the opportunity to comment on publicly disclosed data.

SB 1272 also sets some standards – taken from a settlement agreement involving a number of national insurers — for how insurers may compare and rank health care providers. Insurers would need to:

• show how rankings that include both quality and price weigh each factor
• notify providers of new quality or price ranking indicators
• use appropriate risk adjustment for sicker patients
• describe how performance measures apply when multiple providers are involved in a patient's care
• give providers a right to review the data prior to disclosure
• compare like types of providers in a geographic market

Testifying for the bill were hospitals and BJC Health Systems. Opposing the bill were United HealthCare, St. Louis Business Health Care Coalition and Anthem Blue Cross. Opposition testimony stated that the CMS standards are too limiting and should be expanded.

Birth Certificates

House Bill 1640 has passed the House and is now in the Senate and has been referred to Senate Judiciary Committee.

SB 1640 — Currently, after a parent adopts a child, a court establishes a decree of adoption that may or may not state that the adopted child's birth certificate may be changed to replace a birth parent's name with the adoptive parent's name. This bill establishes the Debbi Daniel Law which disallows a court–ordered adoption decree or the adoptive parents' or adoptee's request for a new birth certificate which changes the name of a birth parent following an adoption.

FISCAL NOTE: No impact on state funds in FY 2009, FY 2010, and FY 2011.

Adverse Events Reporting

The Missouri Center for Patient Safety, the St. Louis Area Business Health Coalition, Anthem Blue Cross, United HealthCare and the Missouri Insurance Coalition all testified today in favor of Senate Bill 916, legislation governing hospitals' response to the occurrence of a "serious adverse event in health care." These are 28 specific incidents defined by the National Quality Forum and are sometimes called "never events." No one presented opposition testimony to the bill.

The purpose of the legislation is to create an environment in which hospitals are encouraged to self–report these rare but serious incidents and work with regulators to develop plans to prevent future occurrences. Additionally, patient safety organizations would be empowered to investigate these and other patient safety incidents and tell other hospitals what lessons can be learned from them. This will encourage the spread of best practices to prevent medical mistakes.

The legislation also requires that hospitals must tell their patients or their representatives that one of the 28 serious adverse events in health care has occurred. Telling the patient of the incident won't be regarded as an admission or acknowledgement of liability.

Midwives

The Senate, once again, debated midwifery legislation this week. The proposed bill would make midwifery legal in Missouri but require midwives to carry malpractice insurance and restrict their ability to administer medication. The bill creates a "Board of Direct–Entry Midwives" within the Division of Professional Registration and gives board the power to issue licenses and to suspend, revoke or deny the license of a direct–entry midwife. The board will develop practice guidelines regarding the practice of midwifery established by the National Association of Certified Professional Midwives, including the development of collaborative relationships with other healthcare practitioners who can provide care outside the scope of midwifery when necessary. Under current law, only nurse midwives partnered with a doctor are allowed to practice. An amendment was offered that would require midwives to be certified by the same board that certifies doctors. The bill was placed on the Senate's Informal Calendar and there is no indication of when debate will resume.

Missouri High–Risk Pool Provision

The bill also would revamp the Missouri Health Insurance Plan, the state's high–risk pool, to offer coverage to individuals unable to qualify for affordable coverage because of medical underwriting risks. The bill would lower the present caps on pool coverage premiums. For those with incomes less than 300 percent of the federal poverty level, the premium would be capped at the standard risk rate. For individuals with higher incomes, premiums would increase with their incomes to a cap of 125 percent of the standard risk rate. If applicants for an Insure Missouri individual policy are denied coverage because of medical underwriting, they will be offered coverage through the high–risk pool, with premium subsidies available.

The measure also redirects the state premium tax paid by some insurers to be earmarked to fund the operation of the high–risk pool. In addition, the pool would offer stop–loss coverage to insurers writing individual policies and, during a two–year pilot project, to insurers providing coverage to small employer groups in Springfield and Kansas City.

HJR 70

With the vote along party lines the House perfected and passed Budget Chairman Allen Icet's controversial constitutional amendment which prohibits appropriations in any fiscal year from exceeding the total state general revenue appropriations from the previous year by more than the appropriations growth limit. The appropriations growth limit will be the greater of zero or the sum of the annual rate of inflation and the annual Missouri population growth. If net general revenue collections exceed 1% of the authorized net general revenue appropriations allowed, 67% of the excess is to be transferred to the Cash Operating Reserve Fund and 33% to the Budget Reserve Fund. Revenues in excess of the limits specified in the bill will be used to permanently reduce the income tax rate rounded to the nearest .25%.General revenue appropriations may exceed the limit only if the Governor declares an emergency and the General Assembly approves the appropriation. New or increased tax revenues or fees receiving voter approval are exempt from the calculation of the appropriations growth limit for the year in which they are passed. One–half of the balance in the Budget Reserve Fund on July 1 of each year is to be transferred to the Cash Operating Reserve Fund and that balance exceeds 5% of the net general revenue collected in the previous fiscal year the excess is to be transferred to the General Revenue. If the Governor reduces expenditures below amounts appropriated in that fiscal year, the Governor may request an emergency appropriation from the Budget Reserve Fund and if approved by the General Assembly, funds may be restored to any expenditure authorized by existing appropriations. If the balance in the Budget Reserve Fund at the end of a fiscal year exceeds 7% of the net general revenue collections for the previous fiscal year, the excess funds will be transferred to the General Revenue Fund. If the balance is less than 7%, the difference will be transferred from the General Revenue Fund within five years. Funds appropriated from the Budget Reserve Fund must be paid back within five years of the original transfer date. The controversial amendment will tough opposition in the Senate.

Core Public Health Funding

The Senate "zeroed" out the House recommended $1.25 million increase in core public health functions.

The vast majority of House recommendations were cut so that the Senate will be able to negotiate a difference in committee.

We need to contact Senators before the floor debate and then when conferees are named contacts will need to be made to take the House position.

I will be visiting with our champion Dr. Cooper this week for his help.

Next Week

Only five weeks remain in the 2008 legislative session. The budget is the main priority as it must be finished by May 9th.

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