Missouri Policy Spotlight: Health Care Access & Pricing
By: Dr. Ramon Martinez III
Health spending in the U.S. has more than doubled in the last 30 years.
A significant portion of high health care costs can be attributed to rising inpatient and hospital prices (Figure 1). A 2019 estimate of $230–240 billion in overpricing was attributed to wasteful spending. State-level policy options to lower these costs include:
- Prohibiting anticompetitive health plan contracts
- Reviewing insurance rates and setting affordability standards
- Requiring pricing transparency in hospitals
- Reducing site-specific facility fees
- Increasing oversight of health provider mergers
- Increasing the pool of patients in the state-negotiated health plans
- Eliminating surprise fees for procuring medical records (HB 1525)
Many states, including Missouri, use Certificates of Need (CON) to regulate spending at certain health care facilities.
CONs are documents required by state laws that allow for the approval of spending for certain projects or service expansion by requiring facilities to demonstrate a local need. CONs aim to control health care costs by restricting duplicative services and determine where community investments are most in need.
In the 2022 legislative session, two proposed bills (HB 1616, SB 890) aimed to eliminate the Certificate of Need process in Missouri.
Research Highlight: Certificates of Need have minimal effect on reducing overall long-term healthcare costs, and can actually decrease the quality of certain kinds of care. Learn more in our Certificates of Need Science Note.
Prescription drug costs in the U.S. are often much higher than in other developed countries.
States have taken various approaches to control prescription costs, such as:
- Regulating activities of Pharmacy Benefit Managers (PBMs)
- Instituting price transparency requirements
- Allowing foreign drug imports
- Requiring reviews of affordability
- Allowing bulk purchasing
- Instituting cost-sharing programs
Research Highlight: Efforts to lower drug prices might reduce innovation incentives for pharmaceutical companies to invent new drugs. For example, 59 anticancer drugs entered the market in the U.S. vs. 46 in Europe between 2004–2008.
Introduced during the 2022 legislative session in Missouri, HB 1677 would have required PBMs to file a report on rebates negotiations and prices paid and retained for those services. Another bill (HB 2305) would have required health insurers to cover all drugs and services when medically necessary. Particular attention has also been paid to:
- Setting cost-sharing caps for insulin
- Expanding pharmacists’ scopes of practice, such as dispensing and insuring addiction mitigation medications and contraceptives
- Allowing for expedited partner therapies
- Authorizing exemptions from step therapy protocols
Learn more in the following Science Notes: Pharmacist Scope of Practice, Pricing & Transparency in Prescription Drug Costs, Contraceptive Accessibility, Prescription Drug Step Therapies, Naltrexone Hydrochloride and Substance Abuse, and Expedited Partner Therapies
Modifications to licensing requirements can be used to attract providers and expand service coverage.
In Missouri, an omnibus bill (HB 2149) signed by the governor expanded the list of professionals who can authorize home health services to include nurse practitioners, nurse specialists, and physician assistants, in addition to doctors. Another approach has been to eliminate oversight needs from a physician for certain professions, such as advanced practice registered nurses (ex. HB 1482).
Several bills, including HB 2149, SB 1002, and HB 2749, aimed to offer license reciprocity for out-of-state health care professionals by providing one-way recognition of out-of-state professional licenses or entering into interstate reciprocal recognition compacts.
Learn more in the following Science Notes: Advance Practice Registered Nurse Scope of Practice, Medical Professional Licensure Reciprocity in Missouri, Interstate Medical Licensure Compact, Home Health Care & Licensing Standards, Counseling Interstate Compact
Medicaid and Affordable Care Act Waivers can be used to control costs and fine-tune services to specific community needs.
Section 1115 waivers: The federal government allows states to apply for waivers that authorize new approaches to state Medicaid programs that differ from federal rules. These changes can include eligibility and enrollment restrictions, benefits restrictions, copays, behavioral health requirements, delivery system reforms, and changes to long-term services. At present, Missouri has two active 1115 waivers:
- Missouri Gateway to Better Health is a waiver program to cover uninsured adults in the St. Louis area, expires December 31, 2022
- Missouri Targeted Benefits for Pregnant Women is a behavioral health program for pregnant women with a substance use disorder to receive treatment and health benefits postpartum, expires December 31, 2026.
Section 1332 waivers: The federal government also allows waivers to specific provisions of the Affordable Care Act (ACA) to meet a state’s healthcare needs. These can include modifications to employer-mandated coverage, limits in cost sharing, differences in benefits, public marketplace standards, and tax credits. Missouri at present has no active 1332 waivers.
Learn more about the Medicaid Program and Section 111 waivers in our Science Note: Work and Community Engagement Requirements for MO HealthNet
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