May 9, 2008

This week as required by statute the General Assembly finished the budget for the next fiscal year. Members of the House have finished budget debate after hearing sobering news about revenue growth. The Office of Administration reports state revenue has grown only 2.2% percent, short of the 3.4% growth on which the budget for the next fiscal year was based.

House Minority Leader Paul LeVota (D–Independence) pointed out during House floor debate that corporate income and franchise tax receipts dropped by more than 11% in April. He said that should sound an alarm. House Budget Committee Chairman Allen Icet (R–Wildwood) agreed that the numbers worried him. Icet did say part of the drop in income from businesses could be, at least in part, attributable to the state giving counties affected by the flooding more time to file.

$22.5 billion state budget begins July first. It cleared two major hurdles with approval of HB 2002 which fund public schools and HB 2003 which funds public colleges.

The education budget totals $5.3 billion and sets aside nearly three billion dollars for public schools. Democrats criticize Republicans for not pouring more money into the classroom. They point out that the new school funding formula hasn't been completely funded.

Republicans rebut the charge. They note that the education budget increases funding for public schools by nearly $120 million and add that the increase provides schools with the largest budget in state history.

The House in particular is moving at a very slow pace. The Republican leadership (Speaker Jetton) has been quoted as "not minding if legislation died this session".

Still only 17 bills have passed and been sent to the Governor. Including 14 appropriation bills.

The Democratic leadership (Minority Leader LeVota) believes that is exactly what the Speaker wants in his final session.

Supporters of HJR 70 — a legislative effort to limit the growth of state government spending — are pleased with the progress they're making, but they concede it's going to be difficult to get the proposal through the Legislature in the final week of the session.

Representative Allen Icet (R–Wildwood), Chairman of the House Budget Committee, says this effort has been attempted in previous sessions, but has never moved to the floor of the Senate or the House for serious consideration. He says a Senate hearing following approval in the House is an indication that progress is being made.

The proposal, if it clears the Legislature, would be sent to a vote of the people. It would ask Missourians to require the General Assembly to cap discretionary spending to the Consumer Price Index plus population growth — but only on General Revenue items. It excludes dedicated taxes like those used for various state departments and would only affect discretionary spending.

News this week includes:

HJR 70

A Senate committee today heard testimony regarding a constitutional amendment that would limit annual state spending. The House already has approved House Committee Substitute for House Joint Resolution 70, which the Missouri Hospital Association opposes. Before appearing on the statewide ballot, the amendment would need approval by the Senate committee and then would need approval by the full Senate.

The constitutional amendment would prohibit, upon voter approval, 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 is the greater of zero or the sum of the annual rate of inflation and the annual Missouri population growth.

For any fiscal year in which the net general revenue collections are in excess of one percent of the authorized net general revenue appropriations allowed, as determined in the previous formula, the excess is to be transferred in equal amounts to the Cash Operating Reserve Fund and the Budget Reserve Fund, which are created by the bill. Any revenue in excess of the specified limits of the funds would be refunded to taxpayers.

Total state general revenue appropriations would be allowed to exceed the appropriations limit only if the governor declares an emergency and the Missouri General Assembly approves appropriation bills to meet the emergency. The funds appropriated to meet the emergency would not increase the appropriation limit for the following fiscal year.

Total state general revenue appropriations would be allowed to exceed the appropriations limit only if the governor declares an emergency and the Missouri General Assembly approves appropriation bills to meet the emergency. The funds appropriated to meet the emergency would not increase the appropriation limit for the following fiscal year.

New or increased tax revenues or fees receiving voter approval will be exempt from the calculation of the appropriations growth limit for the year in which they are passed.

Over 15 groups testified against the legislation citing that the legislatures "hands" would be tied for future years spending even in good times and that a "ratchet" down effect would occur.

Insure Missouri

House committee, chaired by Representative Rob Schaaf, R–St Joseph, heard testimony on Senate Substitute for Senate Committee Substitute for Senate Bill 1283, the Senate version of the Insure Missouri proposal. Several interest groups testified in favor of this bill. However, the committee is expected to substantially change the Insure Missouri proposal with a house committee substitute of the bill and is expected to pass the proposal on Thursday morning. At this time Representative Schaaf had not yet released a house committee substitute.

The Senate version of Insure Missouri in SS SCS SB 1283, is preferable, it contains a plan amendment for the coverage of the uninsured population below 100% of the Federal Poverty Level. The house committee substitute will more than likely remain consistent with previous House Insure Missouri proposals which contain a waiver for all uninsured from 0% to 225% of the FPL. This is an unworkable solution and therefore favors the plan amendment contained in the Senate Insure Missouri proposal is more favorable.

Additionally, Representative Schaaf continues to require some form of Certificate of Need reform be included in any Insure Missouri proposal. This is a killer requirement as hospitals would fight this portion which is the Speaker's plan.

APNs

Senate Bill 724 occupied a great deal of time this week. It provides for prescriptive authority for APNs in a collaborative practice arrangement.

SB 724 — Currently, advanced practice registered nurses have the authority to administer, dispense and prescribe certain drugs while operating under a collaborative practice agreement. This act authorizes advanced practice registered nurses who hold a certificate of controlled substance prescriptive authority from the board of nursing to prescribe controlled substances in schedules III, IV, and V while operating under a collaborative practice agreement. Schedule III narcotic controlled substance prescriptions shall be limited to a 120 hour supply without refill. Certified registered nurse anesthetists do not have this authority.

The act contains requirements that must be contained in all collaborative practice agreements including:

• Names, addresses, and phone numbers of the collaborating individuals.
• A list of offices where the collaborating physician has authorized the APRN to prescribe.


• A requirement that notice shall be displayed at all offices where an APRN is prescribing, that informs patients that they may be seen by an APRN.
• All specialty or board certifications.
• The details of the collaboration including geographic proximity, and how absences are handled.
• A description of the prescriptive authority including a list of controlled substances the physician authorizes.
• A list of all other practice agreements involving the collaborating individuals.
• The duration of the agreement.
• A description of the time and manner of the collaborating physician's review of the APRN's prescribing practices

The act modifies requirements for all collaborative arrangements including the following:

• Physicians shall not collaborate with more than three full time APRNs
• APRNs shall practice for one month in a setting where the collaborating physician is continuously present.
• Neither physicians nor APRNs shall be required to enter collaborative practice agreements.

The act defines advanced practice registered nurse, certified advanced registered nurse practitioner, certified clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist.

The act includes experience and practice requirements that are prerequisites for the board of nursing to grant a certificate of controlled substance prescriptive authority. This act is similar to SB 1255 (2004), SCS/SB 90 (2005), SS/SCS/SB 566 (2006), and SB 511 (2007).

There were two specific sections requiring all physician / APN collaborations be limited to 3 APNs and that an APN must work directly with the collaborating physician for one month.

This would have been a problem for local health departments as they are currently exempted by rule (see below):

Tax Revenues

Below is an article on the sales tax in the state from the Springfield News Leader:

State tax revenue projections create alarm
Senate appropriations chair Nodler sees dire consequences.
DAVID A. LIEB • THE ASSOCIATED PRESS • MAY 5, 2008

Jefferson City — Alarms are sounding in the Missouri Capitol over a sudden downward spiral in state tax revenues. And those concerns already have scuttled millions of dollars of sought–after spending in next year's budget.

Missouri has just two months remaining in its 2008 budget year. As of April 25, things looked pretty good — net general revenues were up 5.7 percent over the same point a year ago.

But in just one week, those revenue figures plummeted. As of Friday, Missouri's year–to–date growth rate over 2007 had fallen to 1.9 percent, according to the Department of Revenue.

Senate Appropriations Committee Chairman Gary Nodler has been ringing the alarm bell.

As House and Senate negotiators hammered out the final details of the 2009 budget, Nodler warned over and over that although things seemed rosy when Gov. Matt Blunt outlined a budget in January, they may very soon turn gloomy.

Nodler used his dire predictions of impending budget troubles to turn back numerous spending increases sought by either Blunt or the House.

Denied were dental and regular eye–care checkups, therapy services and stop–smoking programs for low–income adults on Medicaid.

Denied was Blunt's $375 million plan to expand government–subsidized health insurance to lower–income working Missourians now lacking it, though that was due partly to a policy dispute in the House.

Numerous other programs got less of an increase than had been sought, including sheltered workshops for the mentally disabled, arts and cultural initiatives and the state's Internet–based elementary–and–secondary school.

As legislative budget negotiators debated the virtual school, Nodler warned: "We simply can't sustain all these new program expansions."

Blunt had sought a $1 million increase on top of the current $5.2 million for the virtual school, mainly to expand what is now an elementary and high school program to also serve middle school students.

Budget negotiators ultimately agreed on a $600,000 increase. That should allow courses to expand to middle school, but may limit the number of K–12 students who can participate in the program for free, said Shari LePage, chief budget officer for the Department of Elementary and Secondary Education.

Nodler kept ringing the financial warning bell as negotiations moved along. To more than one lawmaker, lobbyist or interest group, he resorted to an agricultural analogy comparing the budget to a field full of cattle and state revenues to their food.

7q We can't feed all these cows," Nodler said.

Revenue figures released Friday show that Missouri's net general revenues in April were nearly 10 percent lower than they were in April 2007. Both individual and corporate income taxes were down during the month. And although sales taxes were up in April, they remain about 1 percent lower for the 2008 fiscal year as a whole.

Officials from the Department of Revenue met Friday with their counterparts in Blunt's Office of Administration to try to determine the reasons for the declining state revenues.

As revenue employees deposit taxes and mail out refund checks, it's common to see a daily or weekly fluctuation in state revenue totals.

But the recent decline appears to be more than a routine blip, said Larry Schepker, commissioner of the Office of Administration.

"We are concerned about a downturn," Schepker said bluntly. "It's been the concern we've been expressing consistently about what's going to happen to us (because of) the national economy, housing market and increasing price of fuel."

But state officials acknowledge they don't yet know why Missouri's revenues are slipping.

Among the possible explanations: Residents and businesses in 35 Missouri counties approved for federal flood disaster assistance were granted an extension until May 19 to file their tax returns.

That means some of Missouri's revenues may come in later than usual, making the current revenue decline appear more pronounced than is actually the case.

Department of Revenue Director Omar Davis is remaining cautious about declaring Missouri in a financial tailspin.

"At this point, I couldn't definitely say there's cause for concern," Davis said.

Yet that's not to say everything is all right, either.

"I don't know that the concern is as imminent an issue as Sen. Nodler may have believed at that time," Davis said. "But any time you see revenues drop from 5–something percent to 1–something percent, you're going to raise an eyebrow."

Immigration

HB 1626 (Emery) was voted out of the Senate General Laws Committee.

The bill prohibits persons who are not citizens or permanent residents of the United States or who do not possess lawful immigration status from receiving state or local public assistance unless it is mandated under federal law. Documentary evidence accepted by the Department of Revenue for obtaining a driver's license will suffice as proof of citizenship, permanent residency, or lawful immigration status when applying for benefits. Individuals can temporarily receive state or local public assistance for up to 90 days while obtaining the necessary documentation or indefinitely if the applicant provides a copy of a completed birth certificate application which is pending. Nonprofit organizations regulated by the Internal Revenue Service are not required to enforce these restrictions, nor are they prohibited from providing aid.

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

It appears SB 858 will probably be the immigration bill this session. MOALPHA is exempted by Title 8.

Legislature Completes Work on State Budget

On Thursday of this week, legislators wrapped up their enactment of the state operating budget for the fiscal year that begins July 1. In negotiating the difference between the House and Senate versions of the Medicaid and Department of Health and Senior Services’ budgets, the General Assembly made the following allocations.

• MO HealthNet payment rates for doctors' visits and other medical services was increased.
• MO HealthNet spending for physician payments would rise by more than 7 percent, with an additional $39 million in state and federal funding. MO HealthNet currently pays doctors 55 percent of what they would receive for providing the same services under the Medicare program. During the budget year that starts July 1, physician payments would increase to 62.5 percent of the Medicare rate.
• Payments to dentists would increase by 5 percent, with an added $7 million in state and federal funding. Dentists, whose MO HealthNet payments currently amount to nearly 33 percent of the usual private insurance rate, would receive a state increase to nearly 38 percent of the private rates under the negotiated budget.
• Funding for forensic examinations of sexual assault victims was approved for $2.3 million in state and federal funding.
• Presumptive eligibility for the State Children’s Health Insurance Program was approved at approximately $10 million with $3 million for FQHCs.
• Women's Health Program was approved for $13 million in state and federal funding.

Senate Votes On Measure Reversing 2007 Enactment Of Midwifery

The Missouri Senate debated and voted on a measure to repeal an obscurely worded one–sentence provision authorizing the practice of lay midwifery that was passed last year by the Missouri General Assembly. The bill also creates a system of occupational licensure for "direct–entry midwives" who provide obstetrical and postpartum care for a fee.

Senate Committee Substitute for Senate Bills 1021 & 870 would require that these licensed midwives be recognized as certified professional midwives by the North American Registry of Midwives. They must provide patients with written disclosure statements describing their experience, training, liability insurance coverage, risks and benefits of home births and a client–specific plan for transfer to medical care.

A licensure board for direct–entry midwives also would be created in the Division of Professional Registration. Various limitations would be placed on the practice of a direct–entry midwife, who may not prescribe drugs, use forceps during deliveries or perform Caesarean sections, medical inductions or vacuum deliveries.

The bill would limit who may be held liable for negligent acts or omissions by a direct–entry midwife, but it would not preclude other providers from being liable for their own negligence in providing follow–up treatment. The liability language reiterates current legal standards. The bill needs a final vote by the Senate before moving to the House. With very little time left, it is unlikely to pass this legislative session.

Committee Discusses Abortion Bill

A Senate committee advanced a proposal this week to regulate abortion. House Committee Substitute for House Bill 1831 would require that abortions not be performed or induced without the voluntary, informed and uncoerced consent of the patient at least 24 hours before the abortion. It also revises the definition of "abortion" and requires an obstetric ultrasound be conducted before the 24–hour waiting period for an abortion. The bill now moves to the full Senate for debate. It has already received approval by the House.

The bill also would create the crime of knowingly coercing a woman to seek or obtain an abortion. Such coercion includes committing or threatening to do the following:

• abusing or stalking the woman
• committing an offense against the woman or her family
• filing for divorce
• refusing to pay child support or provide financial support
• taking the unborn child once born or the mother's other children
• changing the woman's house or existing residence
• discharging the woman from her employment
• revoking a scholarship awarded to the woman

Next Week

The budget has been completed and there does seem to be any sense of urgency to address many other legislative issues. This is the time of year where numerous amendments will be added both good and bad so vigilance will need to be increased.

Please note there will be no legislative reports sent on May 16th as the legislature will still be in session. There will be a wrap up report the following week.

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