State Rep. Jeff Farnan, R-Stanberry, toured Mosaic Medical Center – Albany on Aug. 27 to learn how the hospital meets the needs of its rural community.

During the visit, hospital leaders highlighted new service lines, including a cancer care clinic that lets patients receive treatment closer to home. Hospital staff noted that the 340B Drug Pricing Program is critical to providing those cancer drug infusions locally.

Rep. Farnan also watched a telehealth demonstration and learned how the hospital’s maternal health care managers and home-visiting nurses support moms and babies who might otherwise travel 30 to 45 minutes to see an obstetrician.

In addition, Rep. Farnan and Katie Dias, D.O., president of Mosaic Medical Center – Albany, discussed workforce shortages, recruitment efforts for physicians and nurses, and how funding from the Rural Health Transformation Program could support rural health care access going forward.

This visit is part of the Missouri Hospital Association’s ongoing work to connect legislators with hospital leaders across the state and help policymakers better understand how legislation affects patient care and hospital operations.

MHA-member hospitals interested in hosting a legislator visit are encouraged to contact MHA's governmental relations team, who can help with scheduling, framing key talking points and coordinating the visit from start to finish.

Among them is HB 2372, a wide-ranging health care bill signed by Gov. Mike Kehoe in July that contains several MHA priorities. Provisions include increased transparency in insurers’ prior authorization practices, modernization of the physician licensure application process, elimination of notary requirements for certain mental health detention and evaluation applications, and protections for insurance coverage of anesthesia services.

The law also includes a new hospital signage requirement that takes effect today. Hospitals must prominently display signage in emergency department and labor and delivery waiting rooms outlining the legal penalties for assaulting health care professionals. MHA has developed ready-to-use signage as part of its Healing Happens Here resources to help hospitals meet the statutory requirement.

Additional provisions of HB 2372 have later implementation dates, including requirements related to real-time electronic prior authorization.

Hospital leaders are encouraged to review MHA’s 2026 Legislative Session Summary for additional information about new laws affecting Missouri hospitals, health care teams and the patients they serve.

State legislators toured two Columbia, Mo., hospitals on Aug. 25 to see firsthand the care these organizations provide to their community.

Reps. Gregg Bush, D-Columbia, John Martin, R-Columbia, and Tim Taylor, R-Bunceton, visited Boone Hospital Center, where hospital leaders discussed workforce demands — including the time and difficulty involved in recruiting and hiring physicians.

Lawmakers also learned about the administrative burden of prior authorization and how physicians often spend hours on the phone appealing insurer denials, which takes time away from patient care. Additionally, hospital leaders shared how many staff each department needs to manage prior authorization, denials and appeals.

Reps. Bush and Martin also toured Landmark Hospital of Columbia, a long-term acute care hospital that bridges the gap between short-term acute care and lower-acuity health care settings. There, leaders discussed how Landmark's specialty care allows patients to keep healing while freeing up beds for patients needing emergency or surgical care. Discussion also centered on payer mix and other challenges facing the hospital.

These visits are part of the Missouri Hospital Association’s ongoing work to connect legislators with hospital leaders across the state and help policymakers better understand how legislation affects patient care and hospital operations.

Any MHA-member hospital interested in hosting a legislator visit is encouraged to reach out to MHA's governmental relations team, who can help with scheduling, framing key talking points and coordinating the visit from start to finish.

The Centers for Medicare & Medicaid Services Region 7 will host a virtual meeting from 10 to 11 a.m. Wednesday, Aug. 26, about taking the pledge and why hospital food matters to patient outcomes. Participants are required to register for the briefing.

Contributing to HEALTHPAC, the Missouri Hospital Association’s political action committee, is an investment in the future of hospitals, health care and the health of Missourians.

With Missouri’s primary election over, and candidates and voters turning their focus to November’s general election, HEALTHPAC is more important than ever in ensuring hospitals have a united, effective voice in decisions that affect health care delivery. In addition, HEALTHPAC helps to amplify hospitals’ voices amid growing competition from other advocacy groups.

Election season provides a critical opportunity to support candidates who understand the issues facing Missouri hospitals, health systems and the communities they serve. MHA directs HEALTHPAC contributions to candidates who have demonstrated support for health care priorities and are committed to strengthening hospitals and access to care statewide.

In 2025, a total of 351 donors contributed $150,859 to HEALTHPAC. There were 144 contributions made to candidates last year.

“Thanks to HEALTHPAC contributions, we get to know elected officials individually and are able to communicate with them one-on-one about our issues,” said Jane Drummond, MHA's general counsel and senior vice president of governmental relations. “Candidates, especially those in their first race or in a tough race, remember who supported them, which fosters good relationships with elected officials.”

Once MHA has established relationships with elected officials, “we are looked upon as a trusted partner in developing policies that are good for the state,” Drummond said. “Elected officials, even those we support, may not always vote how we want them to on a particular bill. However, if we have supported a candidate, they are likely to listen to our position and try to help us find a compromise that works.”

2026 Campaign

The 2026 HEALTHPAC campaign runs through Wednesday, Sept. 30, with a goal of raising $180,000 in contributions.

As of Aug. 8, this year’s HEALTHPAC fundraising goal is 10% met.

Goals also are set for each hospital and health system based on their number of full-time equivalent staff. To meet the goal, MHA suggests each solicitable individual contribute one-tenth of 1% of their salary. For example, a leader who makes $100,000 annually is suggested to contribute $100.

Because each member hospital and health system benefits from the PAC funds raised, it is essential that each member does its part to meet fundraising goals.

A goals flyer and fundraising toolkit are available for download to support hospital solicitation efforts.

How to Contribute

Hospital leaders can contribute to HEALTHPAC in two ways.

• Make a credit card contribution online.
• To contribute by check, use this form. Make checks payable to HEALTHPAC. Submit forms and checks with a transmittal form.
  

AHAPAC

MHA also partners with the American Hospital Association for AHAPAC, a bipartisan PAC supporting federal candidates who back the hospital policy agenda. This year’s goal is to raise $52,700 for AHAPAC.

Contributions to AHAPAC can be made online or by check payable to AHAPAC, using this form and a transmittal form. New AHAPAC donors should contact Christy Carel, MHA's director of membership services, to set up an account.

Learn More

For more information about HEALTHPAC and AHAPAC, including campaign resources, or to make a contribution, visit MHA’s website.

DISCLAIMER: HEALTHPAC is a state-registered, nonpartisan PAC that contributes to candidates and elected officials statewide who share our agenda and champion issues of importance to hospitals and their patients. It provides a vehicle through which hospital employees can participate in Missouri’s political process.

HEALTHPAC can accept personal contributions. It also can accept corporate contributions, but only from for-profit entities. These for-profit corporations must operate under a valid certificate of authority issued by the Missouri Secretary of State. Limited liability companies that have not elected to be classified as a corporation under federal tax law may contribute to HEALTHPAC, provided they have been in existence for one year and registered with the Missouri Ethics Commission. Federal law prohibits corporate contributions by not-for-profit, tax-exempt organizations. Public hospitals also are prohibited by state law from making corporate contributions to PACs.

Contributions to HEALTHPAC are not tax deductible. State laws require us to use our best efforts to collect and report certain information about donors.

Gov. Mike Kehoe recently signed HB 2372, a wide-ranging health care bill that includes a new signage requirement for Missouri hospitals. Starting Friday, Aug. 28, hospitals must prominently display printed signage in the waiting rooms of their emergency departments and labor and delivery departments, outlining the legal penalties for assaulting health care professionals.

To support compliance, the Missouri Hospital Association has developed ready-to-use signage featuring the required statutory language, along with added context noting that the wording and display requirement stem from legislation enacted in 2026. Member hospitals can download this signage now to print and install before the Aug. 28 deadline.

MHA also offers a broader library of customizable print and digital safety signage — available in English and Spanish — through its Healing Happens Here initiative. Explore the full collection of additional resources to reinforce a safe care environment.

For the Tuesday, Aug. 4, primary election, voters hospitalized after 5 p.m. Wednesday, July 22, may request an emergency absentee ballot. Requests can be made through Election Day by contacting their local election authority.

To qualify, patients must be hospitalized or confined within their election jurisdiction or in an adjacent jurisdiction within the same county. If multiple absentee ballot requests come from the same facility, a bipartisan team will deliver the ballots, witness voting, and return the completed ballots and applications to election officials.

Hospital leaders are encouraged to coordinate with their county clerks to help ensure eligible patients can exercise their right to vote.

Learn more about Missouri elections and remember to vote on Tuesday, Aug. 4.

Last week, the Missouri Hospital Association and two hospitals in Jefferson City, Mo., welcomed Jeff Kahrs, regional director for Region 7 of the U.S. Department of Health and Human Services, for a visit focused on the state of hospitals in Missouri.

Kahrs met with MHA staff as well as leaders from MU Health Care’s Capital Region Medical Center and SSM Health St. Mary's Hospital - Jefferson City. During tours of both hospitals, he discussed the 340B Drug Pricing Program and its role in supporting patient care and community services.

At SSM Health St. Mary’s Hospital, Kahrs learned about the “Hope and Healing” Food Bag program, a partnership with Catholic Charities of Central and Northern Missouri. This program provides patients who have been screened for food insecurity with two days’ worth of meals and snacks upon discharge, helping address immediate nutritional needs and support recovery at home.

On July 13, Gov. Mike Kehoe signed HB 2372, a wide-ranging health care bill, into law. The bill contains several Missouri Hospital Association priorities among its provisions, including:

• Transparency in insurers’ prior authorization practices
• Real-time electronic prior authorization of many drugs (starts with the 2027 plan year and reports begin in 2028)
• Streamlining and modernization of the physician licensure application process
• Elimination of notary requirements for certain mental health detention and evaluation applications
• Protections for insurance coverage of anesthesia services

The law also requires that signage concerning legal penalties for violence against health care workers be posted in certain areas of hospitals. MHA will update its Healing Happens Here resources with signage that meets the statute requirements that take effect Friday, Aug. 28.

View a summary of the bill, or the full bill text is available here. 

MHA previously published its 2026 Legislative Session Summary that reviews the outcomes of various legislative proposals that impact Missouri hospitals and health care providers. 

Medicaid hospital reimbursements will not be impacted by any veto or restriction. The governor vetoed language in the Missouri Department of Social Services appropriation bill related to reporting requirements for 340B entities. The full list of vetoes can be found here, and expenditure restrictions are available here.

At its core, the survey is a statewide data engine. It captures the realities of hospital operations — from service lines and staffing to financial pressures and emerging technologies. What makes this survey truly valuable is what happens next: MHA transforms this information into advocacy that shapes Missouri’s health care landscape.

Turning Data Into Action

The Annual Licensing Survey gives MHA staff a comprehensive view of the challenges and opportunities facing Missouri hospitals. Your survey responses provide verified, statewide data that strengthens MHA’s advocacy efforts to shape reimbursement, regulatory policy and care delivery across Missouri in several critical ways:

• Legislative credibility — Lawmakers rely on accurate, statewide information to make decisions. The survey equips MHA with clear, evidence-based insights on issues like workforce shortages, behavioral health capacity and financial strain.
• Policy development — Trends identified in the survey help shape MHA’s policy priorities and guide recommendations to state leaders.
• Resource allocation — DHSS and other state partners use the data to understand utilization, capacity and community needs.
• Supporting materials — The survey powers MHA’s legislative guide, community investment reports and issue briefs that lawmakers depend on throughout the session.

Strengthening Missouri’s Voice Nationally

Because the survey is conducted in partnership with the American Hospital Association, Missouri’s data also contributes to national reporting and advocacy efforts. That means:

• Missouri hospitals are accurately represented in federal policy discussions.
• National ranking and reports reflect the true scope of care delivered in our state.
• Missouri's needs are visible in national debates on reimbursement, regulation and workforce.

 Strong data gives Missouri a strong voice at the national level.

Reducing Burden, Increasing Impact

One of the most important advocacy wins built into this process is efficiency. By consolidating data collection into a single annual survey, MHA reduces the number of requests hospitals receive throughout the year — from us, from DHSS and from AHA.

That means hospitals spend less time reporting and more time caring for patients. And because the data is standardized and comprehensive, it eliminates duplication and ensures every partner — state, federal, association — is working from the same trusted information.

Why This Matters for Missouri

Missouri’s hospitals are essential to the health and economic stability of its communities. To advocate effectively on their behalf, MHA needs more than anecdotes — we need a complete accurate picture of the hospital landscape. The Annual Licensing Survey provides MHA with the information necessary to help:

• protect hospital funding
• support workforce initiatives
• strengthen behavioral health services and resources
• improve access in rural communities
• guide regulatory modernization
• ensure Missouri remains competitive nationally

The Annual Licensing Survey may have started as a regulatory requirement, but its true value lies in what it makes possible: a stronger, more informed, more effective advocacy voice for Missouri hospitals. Your participation does more than meet a mandate — it ensures Missouri hospitals speak with a unified, data‑driven voice. That voice is essential to protecting funding, advancing shared policy priorities and strengthening access to care for communities across the state. 

• establishes a 10-year federal funding program to support rural hospital emergency departments
• provides eligible rural hospitals with at least $1 million annually, with additional funding based on local needs and circumstances
• includes emergency assistance of up to $250,000 for rural hospitals facing imminent closure
• preserves hospitals’ eligibility for other federal health care programs, grants and funding sources 

Joining Hawley at his press conference announcing this legislation were Jon D. Doolittle, Missouri Hospital Association’s president and CEO; Laura Smith, R.N., CEO of Ellett Memorial Hospital & Clinic in Appleton City, Mo.; Aaron Neisen, D.O., a board-certified family physician and emergency department doctor at Scotland County Hospital in Memphis, Mo.; and Mike Poore, CEO of Mosaic Life Care in St. Joseph, Mo. 

Missouri children’s hospital leaders, along with Missouri Hospital Association staff, recently traveled to Washington, D.C., for Children’s Hospital Association Family Advocacy Day. They met with federal legislators and their staff to discuss the 340B Drug Pricing Program and Medicaid, which play an important role in the ability for Missouri children's hospitals to provide care to youth and families across the state.

Joining them was a powerful voice — a patient advocate. A young cancer survivor and her family from Kansas City shared how impactful the nurses and physicians at Children's Mercy Kansas City were in helping with her cancer journey. She discussed how it felt to receive a cancer diagnosis at age 14 and the ongoing care needed, even after her successful treatment.

“Her story allowed us to highlight the importance of the 340B program in helping families have access to specialty drugs, so treatments can begin quickly. This would be made more difficult with a move to a rebate model,” Wolf said.

Hospital leaders and MHA’s advocacy team also discussed the important savings provided by the 340B program that allows hospitals to meet the needs in communities by opening service lines, such as behavioral health, to address the behavioral health crisis facing Missouri youth.

In addition, St. Louis Children’s Hospital staff showcased its Raising St. Louis program during the advocacy event. Legislative staff, families and Children's Hospital Association members stopped by their booth to learn about this program that connects pregnant mothers, fathers and family members in 22 ZIP codes in the St. Louis community with services to build and sustain the family unit.

Raising St. Louis partners with Nurses for Newborns to provide prenatal and postpartum health check home visits to families. The program also offers hospital community health educators certified in the Parents as Teachers curriculum and hospital community health workers to connect families to local resources for health, mental health and early education, often addressing the kind of stressors that can otherwise lead to abuse or neglect.

“When understood and used effectively, cost report data can reveal service line performance, identify reimbursement opportunities and risks, and show how much cost incurred is nonreimbursable or nonallowable,” said Andrew Wheeler, vice president of federal advocacy and finance for the Missouri Hospital Association.

At its core, the Medicare cost report is how the Centers for Medicare & Medicaid Services evaluates hospitals, according to Wheeler. Each year, hospitals are required to submit a cost report after the close of their fiscal year, typically within five months. It is filed electronically with their Medicare Administrative Contractor, which reviews and audits the submission on behalf of CMS.

What does a cost report include?

Cost reports provide a comprehensive view of an organization’s costs, operations and patient mix. The report captures a wide range of information, including the following.

• utilization statistics (including days and discharges) across Medicare, Medicaid and other payers
• patient revenue and expenses
• wage data, including salary and benefits
• departmental costs and charges
• graduate medical education information
• bad debt and uncompensated care data
• capital costs and depreciation
• overhead allocations and statistics
• physician allowable and nonallowable costs

Within the report, certain sections cover critical data.

• Worksheet S-3: Medicare utilization
• Worksheet E series: final reimbursement calculations
• Worksheet S-10: uncompensated care and charity care reporting
• Worksheet A, A-6 and A-8: cost center expenses and adjustments
• Worksheet C: cost-to-charge ratios
• Graduate Medical Education and Indirect Medical Education worksheets
• Worksheet S-3 Parts II, III and IV: wage data used to establish the hospital wage index
• Worksheet G series: hospital financial statement information

Why is a cost report important?

The Medicare cost report is a powerful tool for hospital leaders.

Cost reports help leaders benchmark against peer hospitals, track trends in uncompensated care, evaluate eligibility for various payment programs, and inform advocacy and policy discussions. These reports also offer insight into labor and wage competitiveness and support more informed capital improvement planning decisions.

Additionally, the importance of cost reports extends beyond individual hospitals, Wheeler said.

“Aggregated cost report data help demonstrate the financial realities hospitals face across Missouri, including workforce pressures, uncompensated care burdens and rural access challenges,” he said. “These reports also help support fair wage index calculations and provide data used in state and federal policy development.”

MHA and its data company, the Hospital Industry Data Institute, publish Medicare cost report comparisons annually and share supporting reports used for the Medicare wage index determinations based on CMS wage index reporting and review deadlines.

Where does the data come from?

While finance departments typically lead the process of developing these reports, it requires coordinated input from across an organization, Wheeler said. Revenue cycle and patient financial services teams provide billing and payer data. HR contributes wage and benefits information, while clinical departments supply utilization statistics.

To ensure the cost reports are accurate, hospitals typically use the following.

• accounting and general ledger reports
• patient accounting and billing systems
• payroll and HR systems
• Medicare remittance advice and claims data
• fixed asset systems
• data from electronic medical/health records and other sources

“Although the Medicare cost report is straightforward, optimizing each worksheet and dataset is extremely complex and challenging due to a number of reasons,” Wheeler said.

Hospitals must navigate frequent Medicare policy changes, and there is increasing scrutiny around worksheet S-10 and wage index data. Gathering and coordinating data from across multiple systems as well as departments can be difficult, too. Maintaining consistency between audited financial statements and reported costs also can be a challenge.

Wheeler noted there is a persistent misconception that the Medicare cost report is becoming less relevant and may no longer be used. In reality, the data that cost reports contain continue to drive payment policy, regulatory decisions and more.

Hospital leaders who invest time in understanding their cost report gain a clearer view of their organization’s financial performance and strategic position, Wheeler said.

Gov. Mike Kehoe has until Tuesday, July 14, to sign or veto legislation passed during this year’s session. Legislation signed by the governor will take effect Friday, Aug. 28, unless an emergency clause allows earlier implementation or a bill specifies a later effective date.

Hospital leaders are encouraged to review the issue brief to assess how new laws may affect their organizations and to prepare for implementation. MHA staff appreciates our members’ work to help us advocate on behalf of Missouri's hospitals and the communities they serve.

Contact MHA’s governmental relations team for any questions about the impact or consequences of any legislation listed in the summary.

Lawmakers and legislative staff, including state Sen. Ben Brown, state Reps. Brad Banderman and John Simmons, and Kris Cook, representative from Congresswoman Ann Wagner’s office, toured Mercy Hospital Washington on May 20 to discuss key health care-related issues.

Mercy leaders highlighted growing demand for cardiovascular services, the importance of the 340B Drug Pricing Program and rising administrative burdens tied to prior authorization. Workforce development efforts, including partnerships with Three Rivers College and Lindenwood University, also were discussed.

This visit reflects the Missouri Hospital Association’s ongoing efforts to facilitate hospital visits with lawmakers and connect legislators and hospital leaders across the state. By facilitating these discussions, MHA helps ensure policymakers better understand how legislation affects patient care and hospital operations, strengthening advocacy for Missouri’s hospitals.

Hospital leaders interested in hosting legislator visits can reach out to MHA’s governmental relations team for support and coordination.

Last week, Missouri hospitals welcomed Jeff Kahrs, regional director for Region 7 of the U.S. Department of Health and Human Services, and congressional staff for a series of site visits and discussions highlighting the innovation, challenges and patient-centered care taking place across the state’s health care system. Congressional staff participating throughout the visits included Seth York from Congressman Bob Onder’s office, Kris Cook from Congresswoman Ann Wagner’s office and Jordan Blase from Congressman Wesley Bell’s office.

Throughout the visits, hospital leaders emphasized the critical role hospitals play not only as providers of care, but also as innovators, educators, employers and community partners. Conversations reinforced the importance of thoughtful federal policy decisions that strengthen access to care, support the health care workforce and preserve hospitals’ ability to meet the evolving needs of the communities they serve.

At the University of Missouri, leaders showcased research and education initiatives advancing patient care. The visit included a tour of the NextGen Precision Health building, where interdisciplinary research is driving new treatments and precision medicine. Discussions also highlighted the School of Medicine’s longitudinal nutrition curriculum and a tour of the University of Missouri Research Reactor, a major national source of medical isotopes. At Children’s Hospital at MU Health Care, leaders emphasized the importance of the 340B Drug Pricing Program in sustaining access to specialized pediatric services, supported in part by the hospital’s recently opened 160-bed facility.

During a stop at Boone Hospital Center, Brady Dubois, CEO, and Dr. Lana Zerrer, chief medical officer, discussed the growing challenges patients face navigating Medicare Advantage coverage requirements and the need for prior authorization reform to reduce delays in care and administrative burden on providers.

Leaders at St. Louis Children’s Hospital welcomed Kahrs and Cook for a tour of the hospital’s pediatric cancer and heart and vascular units. Trish Lollo and her team shared stories of lifesaving pediatric care while families spoke directly about their experiences and the critical role physicians, nurses and innovative therapies have played in their children’s journeys. Hospital leaders also emphasized the importance of the 340B program in helping ensure access to cancer treatments and gene therapies for the children and families they serve.

At Mercy, leaders discussed the importance of preserving the 340B program and concerns surrounding proposed rebate models that could create additional administrative complexity and barriers for patients. Mercy leaders also highlighted the system’s telehealth infrastructure and its role in expanding behavioral health services across communities throughout the state. Additional conversations addressed workplace violence in health care settings and the challenges hospitals face balancing employee safety efforts with federal EMTALA obligations. Joining the discussion were Mercy St. Louis Communities President Tricia McGusty, members of her leadership team and Cook.

Leaders at SSM Health Saint Louis University Hospital discussed partnerships with local food banks and nutrition support programs designed to address social drivers of health and improve patient outcomes. Conversations also focused on how 340B supports programs like the hospital’s WISH Center, ongoing workforce shortages — particularly among imaging technicians — and the importance of physician visa programs in helping hospitals meet patient care needs. Blase also participated in the visit. 

U.S. Sen. Josh Hawley, R‑Mo., highlighted priorities for strengthening rural hospitals, including affordability, access and cybersecurity at the American Hospital Association’s Annual Membership Meeting held April 19-21 in Washington, D.C.

Hawley warned that proposed changes to provider taxes in the budget reconciliation bill could harm rural hospitals and urged Congress to act before they take effect.

He also called for doubling funds for the Rural Health Transformation Program and emphasized the need for new, sustainable funding streams. In addition, Hawley addressed rising health care costs, proposing tax‑deductible health care expenses and underscored the growing cybersecurity challenges facing rural hospitals.

Hawley spoke to hospital leaders during a federal forum at the AHA meeting, where he answered questions posed by MHA Board Chair Stephen L. Reintjes Sr., M.D., president and CEO of NKC Health.

Congressional Delegation Meetings

In conjunction with AHA’s meeting, Missouri Hospital Association staff accompanied several MHA-member hospital leaders to Capitol Hill to meet with Missouri’s congressional delegation.

MHA members met with Hawley’s and Sen. Eric Schmitt’s staff as well as Reps. Eric Burlison, Emanuel Cleaver II, Sam Graves, Robert Onder, Jason Smith and Ann Wagner, and staff for Reps. Mark Alford and Wesley Bell.

Discussions focused on the Medicare Advantage reform, site-neutral payment policies, training and retaining newly trained physicians, rural hospital support and sustainability, the 340B Drug Pricing Program, cybersecurity for rural hospitals and a legislative outlook. MHA staff and members thanked their delegation for supporting various pieces of legislation in Congress.

The following leaders and staff from MHA-member hospitals participated in federal advocacy efforts in Washington, D.C., with both MHA and AHA.

• Nick Barto, Ginna Rivera, Steve Bernstetter and Christian Morgan, BJC Health
• Lisa Horn and Dallas Polen, Children's Mercy Kansas City
• Rick Stevens, FACHE, Christian Hospital
• Teresa Coyan, MBA, CoxHealth
• Matthew Fry and Pamela Lanier, Freeman Health System
• Craig Thompson, P.T., MSA, FACHE, Golden Valley Memorial Healthcare
• Raghu Adiga, M.D., Liberty Hospital
• Dr. Reintjes and Richelle Marting, J.D., MHSA, RHIA, CPC, NKC Health
• Jason Shenefield, MBA, FACHE; Jana Cook, MBA, CPA; Casey Burton, Ph.D.; and Arin Sgroi, Phelps Health
• Shawn Dryden, MHSA, FACHE; Ellyn Rosenblum and Kim Buie, Ranken Jordan Pediatric Bridge Hospital
• Jake Vance, Saint Luke's Health - BJC Western Region
• Ellie Harmon, St. Louis Children's Hospital
• Andrew Bagnall, MHA, FACHE, St. Luke's Health Corporation
• Kamera Meaney, M.A., MBA, University Health Truman Medical Center
• Michele Meyer, M.A., BSN, R.N., Washington County Memorial Hospital

Leaders from Missouri’s critical access hospitals gathered April 15 in Jefferson City, Mo., for a Critical Access Hospital Network meeting hosted by the Missouri Hospital Association. During the full-day meeting, attendees learned about updates on several health care initiatives, met for collaborative discussions and visited with their state lawmakers.

Members of MHA’s senior leadership team provided attendees with updates on the Rural Health Transformation Program and workplace safety. Following a legislative briefing, MHA’s governmental relations team and CAH leaders traveled to the Missouri State Capitol to meet with legislators and discuss sustaining access to care in rural communities.

The CAH Network is an MHA engagement group that supports rural hospitals through education, collaboration and advocacy.

“Meetings like this one reinforce MHA’s commitment to strengthening Missouri’s rural health care system and ensuring that critical access hospitals remain positioned to meet the needs of their communities,” said Nate Blackford, MHA’s senior vice president of membership services.

The following Missouri CAH leaders attended the meeting.

• Don Carpenter, CEO, Cedar County Memorial Hospital
• Karla Clubine, CEO, Pershing Health System
• Valerie Davis, administrator, Mercy Hospital Aurora, Mercy Hospital Carthage and Mercy St. Francis Hospital
• Kristen DeHart, CEO, Excelsior Springs Hospital
• Belinda Farmer, administrator, Mercy Hospital Carthage
• Martha Gragg, CEO, Sullivan County Memorial Hospital
• William Hellebusch, administrator, Hermann Area District Hospital
• Nikki Hendren, COO, Harrison County Community Hospital
• Steve Henson, CEO, Ste. Genevieve County Memorial Hospital
• Chris Lang, CEO, Cass Regional Medical Center
• Lisa Lochner, president, Missouri Baptist Sullivan Hospital
• Michele Meyer, CEO, Washington County Memorial Hospital
• Tylie Mills, CEO, Pike County Memorial Hospital
• Blake Riley, COO, Carroll County Memorial Hospital
• Ann Schlueter, CEO, Community Hospital - Fairfax
• Laura Smith, CEO, Ellett Memorial Hospital
• Meagan Weber, CEO, Scotland County Hospital
• Jill Williams, CEO, Samaritan Hospital

The four webinars will take place from 1-3 p.m. Wednesdays from April 22 through May 13. Topics covered will include an overview of the RHTP, the Transformation of Rural Community Health (ToRCH) Care model and the Hub Anchor role.

These informational sessions are timely, as Missouri begins implementing RHTP following recent approval from the Centers for Medicare & Medicaid Services of $216 million in Year 1 funding, covering the period through Sept. 30, 2027. This approval allows the state to move from planning to full implementation of ToRCH Care, the statewide strategy designed to improve access to health care in rural communities.

The funding will be spread across the following five pillars.

• Activating Regional Networks and Local Hubs ($52 million)
• Advancing Sustainability Through Payment Reform ($9 million)
• Laying the Digital Foundation for Long-Term Transformation ($56 million)
• Expanding and Retaining Rural Health Workforce ($18 million)
• Strengthening Rural Providers and Modernizing Service Delivery ($57 million)

An additional $24 million will provide strategic and operational support to coordinate and execute the RHTP statewide.

Learn more and view the detailed funding breakdowns of the Year 1 award.

About the Rural Health Transformation Program

The Rural Health Transformation Program, created under the One Big Beautiful Bill Act (OBBBA), is a landmark federal initiative to strengthen rural Americans' health care access and outcomes through sustainability and innovation. Beginning in 2026, the program provides $50 billion over five years, divided equally between state-distributed funds and competitive grants to states awarded by the Centers for Medicare & Medicaid Services (CMS). Missouri's state-led initiative, known as Transformation of Rural Community Health (ToRCH Care) and coordinated by the MO HealthNet Division within the Missouri Department of Social Services, received a $216 million award from CMS for the first year of the program. ToRCH Care is expected to build local partnerships, expand care coordination and build capacity through a “community hub” model. Rural hospitals, clinics and provider networks are expected to be the primary recipients of these funds. These investments are especially critical as hospitals face future reductions in Medicaid state-directed payments and provider tax matching rates, which disproportionately impact rural hospitals. 

The proposed budget recommends that several programs be eliminated, including the Medicare Rural Hospital Flexibility Program, the State Offices of Rural Health, the Rural Hospital Stabilization Program and the Rural Hospital Provider Assistance Program.

The budget calls for $6.8 billion in funding for the Centers for Medicare & Medicaid Services, which is a $1.4 billion reduction from the enacted FY 2026 budget. The proposal also includes moving the Office of Pharmacy Affairs from HHS to CMS, while increasing funding for the 340B Drug Pricing Program from $8 million to $20.5 million.

The U.S. Department of Health and Human Services and Centers for Medicare & Medicaid Services announced on March 26 the members of the Healthcare Advisory Committee, including Val Huhn, director of the Missouri Department of Mental Health. 

The Healthcare Advisory Committee is a new federal advisory body comprised of leaders from across the health care system tasked with improving, strengthening and modernizing U.S. health care. The committee’s first meeting will be held later this year.

• additional funding for MO HealthNet and Medicaid programs
• funding to begin technology updates for work and community engagement requirements in H.R. 1
• $100 million in authority for the Rural Health Transformation Program

The bill awaits the governor’s signature.

The Missouri Hospital Association’s Physician Executive Group met for the first time this year, and during their visit to Jefferson City, Mo., on March 3, they visited with state legislators at the Missouri Capitol.

This group of MHA-member hospital chief medical officers and physician leaders started their day hearing about public health updates from Heidi B. Miller, M.D., chief medical officer with the Missouri Department of Health and Senior Services, and meeting Mindy Laughlin, new director of the DHSS Division of Regulation and Licensure.

Attendees also learned about updates regarding the Rural Health Transformation Program and discussed workforce retention challenges and opportunities, including funding for medical school clerkships through Missouri’s new Rural Health Transformation Office.

“MHA convenes physician executives to create a dedicated forum where clinical leaders from across the state can learn together, exchange real-world experiences and collaborate on emerging challenges,” said MHA Division Vice President of Membership Services Brett Moorehouse. “By bringing these executives into one room, we strengthen clinical leadership, accelerate innovation, and ensure that hospitals are aligned in improving care quality, patient safety, and system performance statewide.”

In the afternoon, the physician leaders took part in legislative visits with their respective state lawmakers. Topics discussed included prior authorization reforms, physician licensure reforms, the role of advanced practice nurses, emergency department staffing models, managed care denials and delays, and 340B protections.

The following Missouri hospital physician executives attended the meeting.

• Nitin Anand, M.D., Missouri Baptist Medical Center
• Adam J. Fritz, M.D., SSM Health Saint Louis University Hospital
• Alex Garza, M.D., SSM Health
• William M. Gilbirds II, M.D., Saint Luke's North Hospital - Barry Road
• Chakshu Gupta, M.D., Liberty Hospital
• Randall D. Haight, M.D., MU Health Care's Capital Region Medical Center
• Laura Kristy Haggett, D.O., SSM Health St. Joseph Hospital - St. Charles
• Zafar Akram Jamkhana, M.D., SSM Health Saint Louis University Hospital/SSM Health St. Mary's Hospital - St. Louis
• Sean Kumer, M.D., The University of Kansas Health System
• Alexandre Lacasse, M.D., SSM Health St. Mary's Hospital - St. Louis
• Sonia Melkaveri, M.D., SSM Health St. Joseph Hospital - Lake Saint Louis
• Shawn Usery, M.D., CoxHealth
• Sriram Vissa, M.D., SSM Health DePaul Hospital - St. Louis
• Stevan P. Whitt, M.D., MU Health Care
• Lana Zerrer, M.D., Boone Hospital Center
• Nadia Zia, M.D., Barnes-Jewish St. Peters Hospital

Jason Shenefield, president and CEO of Phelps Health in Rolla, Mo., testified about what rural hospitals need to develop and sustain residency programs.

Witness recommendations included adding bridge payments for new residency programs, resetting the per resident caps, fixing the Medicare indirect medical education payment limitation for sole community and Medicare dependent hospitals, and extending the full-time equivalent caps from five years to 10 years for new programs.

This year’s event, held Feb. 17-18, provided valuable networking opportunities and covered a variety of topics, including engaging in strong advocacy, advancing data-driven quality and safety, and strengthening members through leadership development, workforce initiatives and innovative value-added services.

“We understand that hospital leadership is challenging, especially if you are new to the CEO role or simply a new CEO in Missouri. Our two days together provide a unique opportunity for networking and education,” said Nate Blackford, MHA’s senior vice president of membership services.

“In addition to receiving an overview of MHA’s programs and services, attendees get the chance to meet with legislators at the Missouri Capitol, discuss key issues facing hospitals, and build relationships with MHA staff and other health care leaders across the state,” Blackford said.

During the meetings with their respective state legislators, hospital executives discussed the importance of access to health care in the appropriate setting and the vital roles that hospitals play in their communities. These opportunities to meet with lawmakers allow hospital leaders to build and continue enhancing their relationships with members of the Missouri legislature.

The following new Missouri hospital leaders attended this year’s orientation.

• Shivani Bass, CEO, The Rehabilitation Institute of St. Louis-West County
• Christopher Brady, CEO, Kindred Hospital Northland
• David Fredericks, CEO, Rusk Rehabilitation Hospital
• Steve Henson, CEO, Ste. Genevieve County Memorial Hospital
• Tonya Johnson, COO, MU Health Care's University Hospital
• Takisha Lovelace, CEO, The Rehabilitation Institute of St. Louis-St. Peters
• Marie Moore, president, Mercy Hospital Washington and Lincoln Communities
• Justin Morley, interim president/COO, SSM Health St. Mary's Hospital - Jefferson City
• Angelleen Peters-Lewis, president, Barnes-Jewish West County Hospital, and COO, Barnes-Jewish Hospital
• Jacki Pudlowski, administrator, Center for Behavioral Health Maryland Heights
• Billie Jo Russell, interim CEO/chief nursing officer, Iron County Medical Center
• Ann Schlueter, CEO, Community Hospital – Fairfax
• Roger Smyth, administrator, Osage Beach Center for Behavioral Health

Electing leaders who understand the essential role hospitals play in Missouri’s health care system and in the communities they serve is a cornerstone of effective advocacy. MHA’s PAC, HEALTHPAC, is one of the most important tools supporting this work. 

Together, these collective efforts help elect candidates who value hospitals and the patients they care for, while shaping a policy environment that enables hospitals to thrive and deliver high-quality care across the state. 

Thank you for your continued leadership, commitment and support of Missouri’s hospitals and the patients they serve. 

• Rural Hospital Flexibility Program – $70.3 million
• Rural Communities Opioid Response Program – $145 million
• Rural Residency Planning and Development Program – $14 million
• Rural Hospital Maternity and Obstetrics Management Program – $15 million
• Behavioral Health Workforce and Education – $114 million
• Extension of enhanced Medicare low-volume payment adjustments through Dec. 31, 2026
• Extension of Medicare Dependent Hospital program through Dec. 31, 2026
• Extension of Medicare telehealth flexibilities through Dec. 31, 2027
• Extension of the hospital care at home waiver through Sept. 30, 2030
• Prevention of Medicaid DSH funding cuts through Sept. 30, 2027

PolicyHuddle is available online or on your favorite podcast platform. 

• creating favorable operating environments for Missouri hospitals
• evaluating, monitoring and shaping legislation that affects the health care workforce, patient care, liability protections, and holds health plans accountable, while supporting hospital operations
• safeguarding hospitals and the health care system from proposals that would reduce hospitals' ability to deliver on their community-focused missions

MHA staff will continue to monitor all proposals, including any new legislation filed throughout the session, that may impact hospitals and health care.

• enhances Medicare low-volume payment adjustments through Dec. 31, 2026
• extends Medicare-dependent hospital program through Dec. 31, 2026
• extends certain telehealth flexibilities through Dec. 31, 2027
• extends Hospital-Care-at-Home waiver through Sept. 30, 2030
• prevents Medicaid DSH funding cuts through Sept. 30, 2027 

As the appropriations measures change chambers, MHA urges the Senate to pass the legislation.  

A webinar briefing for MHA members is scheduled at 11 a.m. Thursday, Jan. 15, and 1:30 p.m. Tuesday, Jan. 20. 

“This award reflects a shared commitment to improving health care access and outcomes for rural Missourians. From the start, the state engaged primary care providers, behavioral health organizations and hospitals, among others, as key partners in shaping a plan that works for the communities we jointly serve. That collaboration is Missouri’s strength — and it’s why our state's ToRCH CARE proposal stood out nationally.”

The leaders said this funding will help stabilize rural hospitals, expand primary and behavioral health services, and build a workforce pipeline to meet local needs. It also invests in technology and data tools that connect care across settings — ensuring patients experience seamless, coordinated services.

In addition to Gov. Kehoe, they also commended the state's Department of Social Services, including Director Jess Bax, for Missouri's uniquely collaborative approach. Missouri’s Transformation of Rural Community Health (ToRCH) CARE model brings together a wide variety of stakeholders, including clinics, behavioral health providers, federally qualified health centers, EMS, hospitals, physicians, other providers, public health and social-service organizations through regional networks and community hubs. This structure fosters shared accountability and innovation, making care more accessible and sustainable.

The state is expected to finalize its cooperative agreement with CMS and launch implementation of the ToRCH CARE model features in early 2026.

“We congratulate Gov. Kehoe’s administration on a visionary and successful application that earned Missouri one of the nation’s top‑10 awards,” Jon Doolittle, MHA President and CEO, said. “We’re grateful the state included MHA and our member hospitals as key stakeholders throughout the process. This investment will help rural Missourians receive high‑quality care in strong, connected local systems — the kind of care that improves lives and sustains communities.”

What this means for rural Missourians
This cooperative agreement gives the robust network of providers in Missouri's health care system additional tools to extend care where people live — primary, maternal and behavioral health services; workforce pipelines; and the digital backbone that ties it all together.

How Missouri will put the funding to work
Missouri’s plan — built around Transformation of Rural Community Health (ToRCH Care) — advances five practical priorities hospitals will recognize:

• Regional networks and community hubs. Seven coordinating networks and dozens of multi-county hubs will align local partners — hospitals, behavioral health providers, clinics, EMS, public health and social‑service organizations, physicians and other providers, among more — to close gaps and keep people healthier.
• Payment models that reward collaboration. Alternative payment approaches will support care coordination and prevention, not just volume, strengthening hospital sustainability.
• Digital backbone. Interoperable tech and data tools — including referral platforms — will simplify handoffs, track outcomes and reduce friction for patients and providers.
• Workforce pathways. Targeted rural workforce programs will recruit, train and retain clinicians and caregivers to meet local needs.
• Provider transformation support. Hospitals can receive financial and technical assistance to stabilize and modernize operations and care delivery — with measurable improvements in access, quality and cost.

What’s next
Missouri’s Department of Social Services will finalize cooperative agreement terms with CMS, then sequence funding for hub activation, workforce initiatives and tech procurement. The state will continue formal engagement with hospitals and partners with MHA actively facilitating hospital input so implementation reflects real‑world needs.

MHA will continue to issue updates and guidance to members on participating in hubs, data and referral workflows, workforce opportunities and hospital transformation resources.

Background
CMS announced awards on Dec. 29, 2025, to every state under the $50 billion Rural Health Transformation Program, with first‑year awards averaging $200 million.

The Missouri Hospital Association represents the interests of Missouri hospitals by advocating for policies that strengthen health care delivery while blocking or delaying harmful proposals.

In addition to directly advocating on hospitals’ behalf, MHA facilitates hospital visits with state senators and representatives, as well as coordinates federal advocacy visits to Washington, D.C.

In 2025, MHA helped coordinate visits from more than 20 state lawmakers and legislative staff to their communities’ hospitals throughout the state. In addition, MHA has facilitated visits from members of Missouri’s congressional delegation.

“Creating opportunities for legislators to speak with hospital staff and tour facilities helps expand the knowledge for all parties involved,” said Mary Beth Luna Wolf, MHA’s vice president of legal and legislative policy. “Hospital staff and leadership better understand the priorities and pressures on that legislator. In turn, lawmakers have time to ask questions and receive answers that help them understand the impact of policy decisions on their constituents. These visits foster stronger relationships, better education and open lines of communication.”

MHA serves as a powerful, unified voice for Missouri’s hospitals and is privileged to be a trusted partner, advocating for a health care environment in which hospitals can thrive. Learn more about the value of membership and how MHA supports advocacy by connecting lawmakers and hospital leaders.

Gov. Mike Kehoe and the Missouri Department of Social Services announced the appointment of Josh Moore, Pharm.D., as MO HealthNet Division Director, effective immediately. Moore has more than 14 years of experience in pharmacy and public health leadership and has served since 2019 as director of pharmacy for the state’s Medicaid program.   

“Josh brings important experience to his new role leading the MO HealthNet Division," said Jon D. Doolittle, MHA President and CEO. "I'm looking forward to working with him to help MHA's member hospitals and health systems continue to care for the Missourians served by MO HealthNet.”

Representatives from Children’s Mercy Kansas City and MHA staff met this week with staff from all 10 members of the Missouri congressional delegation in Washington, D.C.

During their visit, hospital leaders discussed the importance of continuing to fund the Children’s Hospitals Graduate Medical Education program. Funding for this program helps cover a portion of the cost of training pediatricians and pediatric subspecialists, many of whom will stay and work in the state where they completed their training.

Attendees also discussed the future financial impacts from H.R. 1, including the provider tax provisions and state directed payments.

Attending December’s trip were Dallas Polen and Lisa Horn, from Children's Mercy Kansas City, and Nate Percy, MHA vice president of children’s health and Medicaid advocacy.

ToRCH Care envisions establishing seven regional coordinating networks and up to 30 community hubs of two to five counties each to align goals, represent community- and region-specific differences, and empower clinical and nonclinical partners at the local level to leverage the health improvement work they do best.

All RHTP applications have been submitted by the states. CMS’ input on the Missouri application, and the eventual funding award, are expected by Wednesday, Dec. 31. MHA continues to engage with the state and provider partners to create the systems necessary to launch and maintain the program.

• enhanced Medicare low-volume payment adjustments
• Medicare Dependent Hospital program
• certain telehealth flexibilities
• hospital care at home waiver
• mandatory funding for the Teaching Health Center Graduate Medical Education program

The amendment also would prevent Medicaid DSH funding cuts.

The measure is expected to be voted on in the U.S. House of Representatives Wednesday evening.

• improving health care access for rural Missourians by connecting providers, pharmacies, public health agencies, at-home resources and digital health tools through a unified, regional network
• expanding access to primary care, behavioral health, and maternity services in rural communities while strengthening specialty and complex care through telehealth and patient-focused technology
• enhancing rural provider sustainability by increasing collaboration among local partners to advance technology, operations, and care delivery, and incentivizing better health outcomes through shared savings of avoidable health care costs

CMS will review each state's proposal and notify awardees by Wednesday, Dec. 31.

For more information on Missouri's plan, visit the DSS website or learn more about the RHTP on the CMS website.

What does this mean for hospitals? 

• Medicare payments to hospitals are mandatory and should be unaffected by a government shutdown.
• Medicaid is a mandatory entitlement program and CMS has confirmed there is sufficient funding through the end of CY 2025. CMS’ approval of Medicaid waivers and state plan amendments may be delayed during a government shutdown.
• The Rural Health Transformation Program is mandatory and not impacted by a lapse in government funding.
• Congressional action is needed to extend critical health care programs that expired Sept. 30, including Medicare telehealth waivers and hospital-at-home programs, Work Geographic Practice Cost Index, Medicare rural ambulance add-on payments, and workforce extenders. Delay of the Medicaid DSH cuts is needed, as well.
• CMS issued the following guidance on the hospital care at home waiver: “For all hospitals with active [Acute Hospital Care at Home] waivers, all inpatients must be discharged or returned to the hospital on Sept. 30, 2025, in the absence of Congressional action to extend the initiative. CMS will no longer accept waiver request[s] for participation in the AHCAH initiative after Sept. 1.”
• CMS issued temporary telehealth waivers that will expire on Wednesday, Dec. 31. These waivers include removing eligible geographic and originating site restrictions, allowing audio-only services, permitting different types of providers to administer telehealth services, and continuing tele-behavioral health visits. See AHA’s Telehealth Fact Sheet for additional information.  

The letter also provides guidance on maximizing Missouri’s share of the funds, including how to best calculate the state’s rural factors and conform with the priorities identified by the Centers for Medicare & Medicaid Services. The letter also suggests the state establish performance metrics to evaluate program implementation and ensure that rural health facilities are prioritized for receipt of funding.

The trip included visits with Sen. Josh Hawley; Reps. Jason Smith, Eric Burlison and Sam Graves; and staff from the offices of Sen. Eric Schmitt and Reps. Mark Alford and Bob Onder. MHA staff thank Missouri’s congressional members for working with rural hospitals on policy design, relationship building and long-term strategy.  

MHA President and CEO Jon D. Doolittle along with MHA staff Jane Drummond, Rob Monsees, Andy Wheeler and Mary Beth Luna Wolf attended.  

The following Missouri hospitals and health systems sent representatives on this trip. 

• BJC HealthCare
• Bothwell Regional Health Center
• Citizens Memorial Hospital
• Community Hospital - Fairfax
• CoxHealth
• Fitzgibbon Hospital
• Freeman Health System
• Golden Valley Memorial Healthcare
• Hannibal Regional Healthcare System
• Harrison County Community Hospital
• Hedrick Medical Center
• Hermann Area District Hospital
• Lafayette Regional Health Center
• Mercy Hospital Cassville
• Mercy Hospital Lebanon
• Missouri Baptist Sullivan Hospital
• Missouri Delta Medical Center
• Mosaic Health System
• MU Health Care
• Northeast Regional Medical Center
• Parkland Health Center
• Phelps Health
• Pike County Memorial Hospital
• Ray County Hospital and Healthcare
• Saint Luke's Health - BJC Western Region
• Sullivan County Memorial Hospital
• Texas County Memorial Hospital
• University Health
• Washington County Memorial Hospital

• Enhanced Medicare low-volume payment adjustments
• Medicare Dependent Hospital program
• Certain telehealth flexibilities
• Hospital care at home waiver
• Mandatory funding for Teaching Health Center Graduate Medical Education
• Prevent Medicaid DSH funding cuts

As the continuing resolution crosses chambers, MHA urges the U.S. Senate to pass the legislation.

The full Notice of Funding Opportunity is available online. MO HealthNet will be responsible for submitting Missouri's application through the portal.

About the Rural Health Transformation Program

The Rural Health Transformation Program, created under the One Big Beautiful Bill Act (OBBBA), is a landmark federal initiative to strengthen rural Americans' health care access and outcomes through sustainability and innovation. Beginning in 2026, the program provides $50 billion over five years, divided equally between state-distributed funds and competitive grants to states awarded by the Centers for Medicare & Medicaid Services (CMS). Missouri's state-led initiative, coordinated by the MO HealthNet Division, is expected to build local partnerships, expand care coordination and build capacity through a “community hub” model. Rural hospitals, clinics and provider networks are expected to be the primary recipients of these funds. These investments are especially critical as hospitals face future reductions in Medicaid state-directed payments and provider tax matching rates, which disproportionately impact rural hospitals. 

During their visit, hospital leaders discussed the importance of continuing to fund the Children’s Hospitals Graduate Medical Education program. Funding for this program helps cover a portion of the cost of training pediatricians and pediatric subspecialists, many of whom will stay and work in the state where they completed their training.

Attendees also shared the importance of the 340B Drug Pricing Program, which supports children being cared for in their hospitals, and the future financial impacts from H.R. 1.

This year’s trip attendees included Ellie Harmon, of St. Louis Children's Hospital; Robert Steele, Dallas Polen and Lisa Horn, all from Children's Mercy Kansas City; and MHA staff Mary Beth Luna Wolf, vice president of legal and legislative policy, and Nate Percy, vice president of children’s health and Medicaid advocacy.