Opinion | Johnson: The Hospital Lobby Lives on Your Taxes 

The Missouri Hospital Association is not a patients’ organization. It is a trade group. Its members are hospitals. Its product is hospital revenue. That fact should sit at the top of every hearing in Jefferson City, and every visit MHA makes to the Missouri delegation in Washington.

Follow the money and the picture clears. In hospital finance figures circulated with MHA’s own industry materials, Medicare, and Medicare Advantage account for about 45 percent of Missouri hospital payer mix. Medicaid accounts for about 15 percent. ¹ MHA’s community-benefit releases put it in human terms: Medicare beneficiaries account for half the care delivered in Missouri hospitals; Medicaid accounts for about 18 percent, including a large share of births and children’s care. ² Those are not side accounts. They are the core business.

Then the association does something that only makes sense if you remember it is a trade group. It reports hundreds of millions of dollars in “unreimbursed” Medicare and Medicaid costs. More than $440 million in Medicare and $811 million in Medicaid in one recent statewide tally and uses that gap as the argument for more public money. ³ The programs that already dominate the revenue are said to underpay. Therefore, Congress and the General Assembly must send more. The taxpayer is both a customer and a residual insurer. The loop never closes.

Watch the annual agenda. Higher Medicare rates. Delayed Disproportionate Share Hospital cuts. Defense of the Federal Reimbursement Allowance, the provider of tax that levers federal Medicaid dollars into Missouri hospitals. Wage-index fights. Protection of 340B. That is not an emergency list. It is the standing invoice. ⁴ MHA’s own wrap-ups boast of the wins: tens of millions in FRA general revenue, wage-index adjustments in the hundreds of millions, psychiatric add-ons, boarding money. Those are tax dollars. They are not foundation grants.

None of this is hidden, and none of it is illegal. Trade associations exist to enlarge the stream that feeds their members. The failure is downstream in the way officials and voters are invited to hear the pitch. “Safety net” is the language. “Community-focused mission” is the language. “Harmful legislation” is what they call a bill that would make a hospital post a cash price a family could use. Translate it and the sentence is simpler: do not touch the public payment streams, and do not make us compete on a number the patient can read.

When Missouri lawmakers tried to attach real state penalties to hospitals that ignore federal price-transparency rules, MHA called the extra enforcement a burden. ⁵ The association later counted among its accomplishments helping to stop the federal Lower Costs, More Transparency Act. ⁶ What it will offer instead is a portal it controls (MissouriHealthMatters.org), statewide averages, quality snapshots, community-investment figures, refreshed on its schedule. ⁷ That is not the same thing as the cost of the surgeon, facility, and anesthesia on one page before the procedure. A dashboard is not a price. A trade group will always prefer the dashboard.

This is the expose, and it is not a conspiracy. It is an income statement. Hospitals in Missouri are, to a remarkable degree, vendors to the federal Treasury and to MO HealthNet. The association that represents them is organized around that fact. When the programs underpay, the ask is not “rethink the 1965 design.” The ask is “fill the gap.” When a model appears that keeps people out of the building—Direct Primary Care, a posted-price surgery center, a sharing ministry that pays cash—the association has no institutional reason to cheer. Empty beds do not fund dues.

The alternatives still matter, and they still work. Patients who pay a flat monthly fee for unlimited primary care use the emergency room less and land in a hospital bed less often. ⁸ Facilities that publish an all-in cash price routinely undercut the insured hospital bill by half or more. ⁹ Voluntary cost-sharing ministries run on monthly shares far below many individual premiums. ¹⁰ Those models treat the patient as a customer. The dominant hospital model treats the patient as a claim attached to a public or private third party. MHA is built for the second world.

Rural hospitals are in genuine trouble. That fact is real, and it does not require anyone to pretend otherwise. It also does not require a blank check. A struggling hospital that will not post a usable cash price is still hiding the price. Distance does not make opacity a virtue. Officials can stabilize a rural balance sheet and still require a number a farmer can read. The association will try to separate those two acts. They travel together.

What should change is not the right of hospitals to lobby. What should change is the habit of treating MHA’s agenda as if it were the patient’s agenda. Expand Health Savings Account rules so Direct Primary Care fees and direct pay procedures qualify cleanly. Enforce cash prices people can use, not charge-master PDFs no one can decode. Protect sharing ministries from being regulated as insurance. Let self-insured employers keep contracting around the maze; many already have. Attach conditions to the next public transfer: a posted price, a path to direct-pay primary care, an end to the claim that transparency is a burden.

Medicare and Medicaid were sold as shields against medical bankruptcy. In Missouri, they have also become the core cash register of the hospital industry and the organizing principle of its lobby. That is the story the association would rather tell as “mission.” It is more honest to tell it as dependence. Taxpayers already buy most of the products. They are entitled to a price, a choice, and a system that does not need another appropriation every year to remain.