Dr. Quinn James testified in the Missouri Capitol for nine years before lawmakers passed legislation in 2018 that allows chiropractors like him to provide services through the state's Medicaid program.
What convinced lawmakers to get behind the legislation, James told The Independent, were predictions that it could help the state spend less on Medicaid.
The Missouri Department of Social Services, which administers the state's Medicaid program, MO HealthNet, estimated in 2018 that the change could save $8.9 million to $12 million in state general revenue in the first two full years of implementation.
The idea was that by allowing Missourians to use their Medicaid coverage to go to chiropractors, the state could avoid paying for costly back surgeries or emergency room visits, said James, a chiropractor in St. Peters and former legislative chairman for the Missouri Chiropractic Physicians Association.
But under the budget passed by lawmakers in May, MO HealthNet will no longer cover chiropractic services starting July 1. Funding for physical therapy and acupuncture services for chronic pain will also be eliminated.
Republican state Rep. Darin Chappell of Rogersville introduced the amendment removing the $658,660 from MO HealthNet's budget for fiscal year 2027.
Chappell, who chairs the House subcommittee overseeing the budget for state's social services department, told The Independent he was informed by department officials earlier this year that they had "no hard evidence that the program saved the state any money" and that he introduced the reduction as a way "to cut the budget that has the least amount of impact."
But chiropractic services advocates said they weren't consulted about the change and didn't know about the cut until the budget was already approved and on its way to the governor's desk.
Chappell said when he discussed the cut with the department, he was told that about 2,000 Medicaid recipients use the chiropractic benefits per year. About 1.3 million Missourians were enrolled in MO HealthNet in April, according to department data.
"Without the hard data, the department's position was that this was an option that was used by a small minority, relatively, to the overall population that did not [cause] provable savings to the state," Chappell said. "And therefore they did not fight to maintain that program when we were facing the need for such extraordinary budget reductions."
Lawmakers cut $375 million from the general revenue spending suggested by Kehoe in a drive to trim the budget as the state's surpluses shrink. State Auditor Scott Fitzpatrick said in a report this week that even with those cuts, the state is on track to exhaust surplus funds in the second half of 2027.
Asked about the rationale behind the cut, Baylee Watts, a spokesperson for the social services department, said the agency "does not comment on budget matters while they remain under review by the executive branch and pending final action by the governor."
Kehoe has until the end of June to sign or veto state spending bills.
While the federal government requires state Medicaid programs to cover some benefits, like hospital care and physician services, chiropractic services are an optional benefit that states can offer with approval from the U.S. Centers for Medicare & Medicaid and subject to appropriation by lawmakers.
MO HealthNet began covering chiropractic treatments for patients diagnosed with chronic pain conditions in April 2019 as part of a program to reduce opioid misuse. The program, which requires a physician's referral and pre-certification, also includes physical therapy and acupuncture.
Missouri started covering chiropractic services for all MO HealthNet recipients in January 2020.
Transparency concerns
Derek Leffert, executive director of the Missouri Chiropractic Physicians Association, said he didn't know about the cut until The Independent reached out for an interview in early June.
"We track the budget for the organization and what that means for the chiropractors in the state," Leffert said. "This was done kind of under the cloak of darkness."
James said he found out about the cut a few days earlier, when a friend sent him a screenshot of an email from the department to managed care organizations about the change.
Chappell said no one expressed concerns about the cut to him during the legislative session.
"It's an unfortunate set of circumstances, but those hearings are public, and the amendments that I filed were public record," Chappell said.
Lawmakers typically hear public testimony about the version of the budget recommended by the governor early in the legislative session. On Feb. 11, dozens of Missourians traveled to the Capitol to urge lawmakers to restore $80.7 million in proposed cuts to services that help people with developmental disabilities stay in their homes and communities. Lawmakers restored all but $1.6 million of those cuts.
Chappell's amendment impacting chiropractic services was included in the budget approved by the House on March 24, but it was not specifically mentioned during debate. The Senate did not hold public hearings on budget bills. And the cut is part of a larger budget line including various types of care, such as podiatry and diabetes prevention, making it more difficult to see what services would be impacted.
Leffert said members of the public didn't have any meaningful chance to provide feedback on the proposed cut.
"There was no opportunity for constituents to engage with the legislators to say, 'Hey, this is a bad idea,'" Leffert said.
Chappell said that while the department informed him that 97% of MO HealthNet enrollees who received chiropractic services did not undergo back surgery, it's unclear whether those people would have gotten surgery if chiropractic care hadn't been covered.
Still, James said defunding Medicaid coverage of chiropractic services is short-sighted.
"When you take away a competing provider group that's providing a cost-effective treatment, and you force that patient into an area where they have to go to the emergency room to get the same care for that condition," James said, "all you've done is you've replaced lower-cost care with higher-cost care."
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