Is choice coming to the ballot?

By Wally Kennedy

wkennedy@joplinglobe.com

A Springfield group, Missourians United for Choice in Healthcare, has the green light to circulate an initiative petition that — if eventually approved — could change health care in Joplin.

Proponents claim the proposal would guarantee all Missourians greater choice in health care, and open up markets in Springfield and Joplin where they say residents are not given choice. Critics say the plan would further drive up health care costs and make health care more difficult for many in Missouri to afford.

But there are hurdles the advocates must clear first. The petition must receive signatures from registered voters equal to 8 percent of the votes cast in the 2008 governor’s election in six of the state’s nine congressional districts. That equates to about 385,000 signatures. And that has to be done no later than 5 p.m. May 2.

Then the issue would have to be endorsed by voters on the Nov. 2, 2010, ballot.

Ballot language for the petition recently was approved by Missouri Secretary of State Robin Carnahan, but even that is being challenged in Cole County Circuit Court at Jefferson City. Laura Egerdal, communications director for Carnahan, said such challenges are not uncommon for initiative petitions.

“They could begin gathering signatures now, but many choose to wait until the legal process plays out,’’ Egerdal said. “If they wait until the legal process is over to gather signatures, they can be sure of the actual ballot language and that their signatures are valid.

“If they work to gather signatures now and the court upholds the ballot language, those signatures would be just fine. If not, they would have to start over.’’

She said the legal challenges in court are “incredibly common because the petitions often involve controversial issues. People have strong opinions on both sides and on how the ballot language needs to be worded.”

Battleground

Missourians United for Choice in Healthcare (MUCH) is based in Springfield, but it has ties to Joplin. That’s because Southwest Missouri is viewed as a battleground over choice in health care. Proponents claim that Springfield and Joplin, as well as St. Joseph, are the major cities in the state where patients with private insurance must see only doctors affiliated with certain hospitals because of contracts between the health systems and insurance companies. Patients who go out of that network pay more.

Dr. Marsha Taylor, of Nixa, filed the initiative petition that was certified by Carnahan.

On Wednesday, she said: “What we hope to do is break the monopolies that exist in St. Joseph, Springfield and Joplin.

“We want to be able to choose the best provider for the dollar. How can you do that when the market is closed?

“It has boiled down to a ‘We the People’ issue,’’ said Mike Pence, a Joplin businessman and longtime supporter of choice in health care.

The battle over choice in health care first surfaced in Joplin two years ago between Freeman Health System and St. John’s Regional Medical Center. It arose when a local group, Choice in Health Care, began campaigning to open up what it said was a “restricted” health care market.

“Freeman,” the group alleged at the time, “has refused to open its networks and allow choice. In fact, (Freeman) threatened to raise (its) prices if people were allowed to choose. Freeman has told people they can’t have access to both hospitals — or else they will unilaterally raise their prices to punish them. Their threat is that they will not participate in the future if forced into any health care network that offers choice of Freeman or St. John’s.”

Last year, when St. John’s announced 160 layoffs, the interim CEO at the time, George Caralis, cited competition over commercial insurance contracts as one of the “battles” the hospital was fighting.

Heath care choice bills before the Missouri General Assembly failed to gain traction each of the past two years. A bill passed the House in 2008, but came too late for the Senate to act. That bill was reintroduced during the 2009 session, but did not make it out of the House Healthcare Committee.

“There were 10,000 people who signed petitions in support of that legislation,’’ Pence said. “The hue and cry did not motivate anyone to help us who was in a position to do so.’’

That’s why proponents of choice are turning to the initiative petition process.

“It’s the only way that we can get choice in health care from the standpoint of choosing our providers. The only way is through an initiative petition,’’ Pence said. “We can’t get it through legislation. I am convinced of that.’’

‘Premature’

Local hospital officials in Joplin and Springfield are reluctant to talk about the initiative petition and how it might affect their operations or whether they might fund a statewide fight — either directly or indirectly — to defeat the measure should it reach the ballot.

Questions about the petition were posed to Gary Duncan, president of Freeman Health System, who deferred them to Heather Collier, media spokeswoman for Freeman. She said, “At this time, we feel it is too premature to comment on this due to the number of unknowns.’’

However, Freeman officials have said in the past that the “choice” issue is one of sour grapes because St. John’s lost contracts with major employers, such as the Joplin school district and the city of Joplin. Freeman officials also have said they can keep prices low with health plan contracts that offer discounts in exchange for large groups of patients who must seek care there.

Caralis previously acknowledged that Freeman’s strategy has given it about 60 to 65 percent of the private insurance contracts.

Duncan, however, has also said previously it is difficult to quantify the savings to patients from the system now in place.

“Insurers will raise prices when they are not sure of volumes,” he said earlier this year. “It’s just that simple. That’s the thing that is going to drive pricing.”

In the past, St. John’s Regional Medical Center has supported choice in health care. Pence is a former chairman of the board of St. John’s Regional Medical Center.

But ownership of the medical center recently changed from Catholic Health Initiatives to Mercy Health System, which operates hospitals in Springfield, St. Louis and elsewhere.

Shelly Hunter, vice president of strategy and business development at St. John’s, said, “We are still in the very early weeks of the transition and we are studying many issues, including AWP (Any Willing Provider) legislation. Given our focus on ensuring a smooth transition from CHI to Mercy, it would be premature for us to present a position on the issue until we have had a chance to fully explore it.”

Yvette Mitchell, spokeswoman for Cox Health System in Springfield, said Cox also is deferring comment “to the Missouri Hospital Association, which is looking into the issue. We are transferring all of these requests to the MHA.’’

Dave Dillon, spokesman for the Missouri Hospital Association, said: “The board has not made any comments or taken a position on the petition. We’re in the waiting and discussing period.’’

But the Missouri Hospital Association, the Missouri Chamber of Commerce and Industry, and Anthem Blue Cross and Blue Shield have opposed the previous legislation; proponents include the Missouri Retailers Association and the Missouri State Chiropractors Association.

The initiative petition would prohibit state-regulated health insurers from influencing the selection of a health care provider through higher co-pays or reimbursements, and from limiting a provider’s opportunity to offer services according to terms of an offered health benefit plan.

Insurers often use such restrictions in order to bargain with providers for reimbursement rates that are lower.

Brent Butler, spokesman for the Missouri Insurance Coalition, said, “We’re against it and we were against it when it was proposed legislation. We think, basically, that it would make health care more unaffordable in Missouri.’’

Butler said choice in health care is a statewide issue, but that Southwest Missouri “is the battleground.’’

Pence said, “Choice is a statewide issue, it’s just that we experience it more here. It’s a two-hospital market in Joplin and Springfield. The bigger markets, Kansas City and St. Louis, have more hospitals. There are eight hospital corporations doing business in St. Louis. An insurance provider there might let a patient have access to half of them, but they are all steered. They do not have choice. They have to go to hospitals that have their insurance contracts.

“We see it and feel it more forcefully here in Southwest Missouri. It’s one or the other for us. We don’t want that steerage.’’

Ballot language

But first, proponents have to get past a legal challenge to the petition language that was filed by Jefferson City attorneys Alex Bartlett and Robert Hess.

Hess would only say that “individuals” are backing the court challenge to both the wording the “fiscal note” attached to the proposal.

The fiscal note says it is estimated the Missouri Medicaid program will have one-time costs of $100,000 and unknown future costs. State and local governments that use self-funded benefit plans may be adversely affected, but the total costs are unknown.

Taylor, the Nixa physician, said the parties “paying the bill for one of Jefferson City’s largest law firms to fight this will be identified in court. We think some of the state’s larger hospitals are behind this.’’

The language in the initiative petition was patterned from a similar initiative in Arkansas, which was approved by voters, she said.

“Arkansas did not see a huge increase in premiums after it was passed there,” Taylor said. “Free markets tend to lower costs,” she added. “The current arrangement does not allow a free market to occur.”

Holly Cuoco, a Springfield resident and one of the leaders of the petition drive, said, “We hope to have the lawsuit resolved by the end of this month. Once it is OK, we’ll start the signature gathering for the petition. Once that starts, it will be a fast process.’’

She said it is possible MUCH could hire one of two companies in Missouri that do signature gathering on a statewide basis.

“It’s going to be a struggle. It’s expensive to do this kind of thing, but we want what more than 30 other states already have. We want choice,’’ she said. “We are going to be fighting people who have lots of money who do not want this to happen. But there are a lot of people on our side who believe in this.’’

Pence concurred with that assessment.

“How are we going to raise the $5 million to do the TV work that needs to be done in the two weeks before the vote next year? You can bet the commercial insurance lobby and Missouri’s hospitals will have a lot of money to spend on TV to vote it down,’’ he said. “There’s a real inequity in the battlefield.’’

Cuoco until recently was a cancer survivor. Since her cancer has returned, she is fighting harder than ever for choice in health care.

“When you ask people whether they want to be able to choose their own doctor, they almost always say ‘yes,’ ’’ she said. “For me, I want to stay with the doctor who saved my life.’’

Who’s affected

Travis Ford, spokesman for the Missouri Insurance Commission, said there are 123 health insurance providers in Missouri. The number includes those that provide Medicare supplemental plans.

“More than half of Missouri’s insured population are not licensed by us. That would include those on Medicare and Medicaid. The self-insured also are not counted in that number,’’ he said. “The state of Missouri has a self-insured plan, as do most large governments in the state and big companies.’’

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