COMMITTEE ON LEGISLATIVE RESEARCH
OVERSIGHT DIVISION
FISCAL NOTE
L.R. No.:1261H.01I Bill No.:HB 489 Subject:Education, Higher; Health Care; Boards, Commissions, Committees, and
Councils; Professional Registration and Licensing
Type:Original Date:March 3, 2023Bill Summary:This proposal creates provisions relating to health care.
FISCAL SUMMARY
ESTIMATED NET EFFECT ON GENERAL REVENUE FUNDFUND AFFECTEDFY 2024FY 2025FY 2026General Revenue$0 to (Unknown)$0 to (Unknown)$0 to (Unknown)Total Estimated Net
Effect on General
Revenue$0 to (Unknown)*$0 to (Unknown)*$0 to (Unknown)*
*Oversight assumes the loss to be less than $250,000 annually.
ESTIMATED NET EFFECT ON OTHER STATE FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Other State$0 to (Unknown)$0 to (Unknown)$0 to (Unknown)LEF* $0$0$0Colleges and
Universities$0 to (Unknown)$0 to (Unknown)$0 to (Unknown)
Total Estimated Net
Effect on Other State
Funds$0 to (Unknown)$0 to (Unknown)$0 to (Unknown)
*Indicates numbers net to $0.
Numbers within parentheses: () indicate costs or losses. L.R. No. 1261H.01I
Bill No. HB 489
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ESTIMATED NET EFFECT ON FEDERAL FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Federal$0 to (Unknown,
potentially significant)
$0 to (Unknown,
potentially significant)
$0 to (Unknown,
potentially significant)
Total Estimated Net
Effect on All Federal
Funds
$0 to (Unknown,
potentially
significant)
$0 to (Unknown,
potentially
significant)
$0 to (Unknown,
potentially
significant)
*Oversight notes DMH’s assumption of loss of federal funding for non-compliance with DEI
provisions and the resulting loss of facilities’ accreditations could be significant; DMH noted a
possible maximum loss of $2.2 billion annually.
ESTIMATED NET EFFECT ON FULL TIME EQUIVALENT (FTE)FUND AFFECTEDFY 2024FY 2025FY 2026Total Estimated Net
Effect on FTE 000
☒ Estimated Net Effect (expenditures or reduced revenues) expected to exceed $250,000 in any
of the three fiscal years after implementation of the act or at full implementation of the act.
☐ Estimated Net Effect (savings or increased revenues) expected to exceed $250,000 in any of
the three fiscal years after implementation of the act or at full implementation of the act.
ESTIMATED NET EFFECT ON LOCAL FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Local Government$0 to (Unknown)$0 to (Unknown)$0 to (Unknown) L.R. No. 1261H.01I
Bill No. HB 489
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FISCAL ANALYSIS
ASSUMPTION
§§191.1770 through 191.1810 – Do No Harm Act
Officials from the Department of Mental Health (DMH) state the proposed legislation
establishes the “Do No Harm Act” under sections 191.1770 to 191.1810.
Section 191.1775(3) defines "health care provider" as "any public hospital or public health care
provider including, but not limited to, physicians' offices, outpatient clinics, medical testing sites,
medical laboratories, physical or occupational therapy or rehabilitation providers, chiropractors,
dentists, optometrists, mental health and clinical social workers, and related providers".
Section 191.1795 prohibits health care providers and medical institutions of higher education
from adopting or imposing any type of diversity-equity-inclusion (DEI) training, education,
material or program as a condition of obtaining or renewing licensing.
Section 191.1800 would require any state entity applying for a federal health care grant related to
DEI to publish materials on their website and submit copies to the state board of registration for
the healing arts and to the legislative committees on health policy. The Department of Mental
Health (DMH) inpatient facilities are accredited by The Joint Commission (TJC) and Center for
Medicare/Medicaid Services (CMS). TJC and CMS set several standards that facilities are
required to meet for accreditation; cultural competency is included in seven areas of TJC
Standards and in three areas of CMS hospital Conditions of Participation. Loss of accreditation
by DMH facilities would result in the loss of federal funding. The fiscal impact may include the
loss of federal funding estimated to be $0 - $2.2 billion.
Additionally, DMH offers training for various clinical disciplines. Various regulatory bodies
oversee the training of these clinicians and specify the need to incorporate cultural competency.
For example, the Accreditation Council for Graduate Medical Education (ACGME) has
recognized cultural competency as a part of three out of six core competencies (patient care,
interpersonal and communication skills and professionalism) that residency training programs
are to provide training in. Loss of training sites would lead to further shortages in clinical
disciplines and it may cause a safety issue to individuals in DMH care if at the last minute there
are providers DMH can no longer contract with. This may cause an unknown impact to the
department.
Oversight does not have any information to the contrary. Oversight has no information on the
amount of federal funding that could potentially be lost. In addition, Oversight has no
information relating to the likelihood of a loss of training sites that could be used by DMH if
they offer DEI training. Therefore, Oversight will reflect $0 to Unknown costs to General L.R. No. 1261H.01I
Bill No. HB 489
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Revenue (assumed to be less than $250,000 annually) and a $0 to Unknown, potentially
significant, loss in Federal funds for this agency.
Officials from the Office of Administration (OA) state provisions of §191.1802 have the
potential to increase costs to the state Legal Expense Fund (LEF) for actions alleging violation of
this provision against a state employee in connection with their official duties on behalf of the
state or against another person covered by the LEF, due to the addition of an enforceable right
under this section. This provision also waives sovereign immunity. This change will be subject to
judicial construction; therefore, the cost impact to the state is unknown.
The state self-assumes its own liability under the LEF, §105.711 RSMo. It is a self-funding
mechanism whereby funds are made available for the payment of any claim or judgment
rendered against the state in regard to the waivers of sovereign immunity or against employees
and specified individuals. Investigation, defense, negotiation or settlement of such claims is
provided by the Office of the Attorney General. Payment is made by the Commissioner of
Administration with the approval of the Attorney General.
Because this bill creates a possible new cause of action, Oversight will show a net $0 direct
fiscal impact for the LEF, and a possible $0 to (unknown) fiscal impact to General Revenue and
other state funds. Oversight notes this possible litigation exposure as described by OA could also
apply to colleges and universities, federal funds, as well as local political subdivisions.
Officials from the University of Central Missouri
fiscal impact on their organization.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect a $0
to unknown cost for colleges and universities for fiscal note purposes.
Officials from the Office of Attorney General (AGO)
arising from this proposal can be absorbed with existing resources. However, the AGO may seek
additional appropriations if there is a significant increase in litigation.
Oversight does not have any information to the contrary. Therefore, Oversight assumes the
AGO will be able to perform any additional duties required by this proposal with current staff
and resources and will reflect no fiscal impact to the AGO for fiscal note purposes.
Oversight notes provisions in §191.1805.3 provide that the AGO may seek civil penalties up to
$1 million for violations. In addition, it is thought since these penalties would be for a violation
of civil law rather than criminal law, the penalties would not be distributed to school districts.
Oversight assumes any civil penalties collected by the AGO would be deposited in the General
Revenue Fund. Since it is unknown whether any penalties will be collected, Oversight will range
the penalties from $0 to Unknown. L.R. No. 1261H.01I
Bill No. HB 489
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Officials from the Missouri House of Representatives (MHR) state the proposal will have no
impact, assuming the General Assembly will be in session when it needs to act.
Oversight does not have any information to the contrary. Oversight assumes the MHR will have
no fiscal impact based on their assumption.
Officials from the Department of Commerce and Insurance, the Department of Elementary
and Secondary Education, the Department of Higher Education and Workforce
Development, the Department of Health and Senior Services, the Department of Social
ServicesSt. Charles Community CollegeOffice
of the GovernorMissouri Senate, the Missouri Office of Prosecution Services and the
Office of the State Courts Administrator each assume the proposal will have no fiscal impact
on their respective organizations. Oversight does not have any information to the contrary.
Therefore, Oversight will reflect a zero impact in the fiscal note for these agencies.
Rule Promulgation
Officials from the Joint Committee on Administrative Rules assume this proposal is not
anticipated to cause a fiscal impact beyond its current appropriation.
Officials from the Office of the Secretary of State (SOS) note many bills considered by the
General Assembly include provisions allowing or requiring agencies to submit rules and
regulations to implement the act. The SOS is provided with core funding to handle a certain
amount of normal activity resulting from each year's legislative session. The fiscal impact for
this fiscal note to the SOS for Administrative Rules is less than $5,000. The SOS recognizes that
this is a small amount and does not expect that additional funding would be required to meet
these costs. However, the SOS also recognizes that many such bills may be passed by the
General Assembly in a given year and that collectively the costs may be in excess of what the
office can sustain with its core budget. Therefore, the SOS reserves the right to request funding
for the cost of supporting administrative rules requirements should the need arise based on a
review of the finally approved bills signed by the governor.
Oversight only reflects the responses received from state agencies and political subdivisions;
however, other colleges and universities were requested to respond to this proposed legislation
but did not. A listing of political subdivisions included in the Missouri Legislative Information
System (MOLIS) database is available upon request. L.R. No. 1261H.01I
Bill No. HB 489
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FISCAL IMPACT – State GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026GENERAL REVENUE FUNDIncome – AGO (§191.1805) – civil
penalties collected p.4$0 to Unknown$0 to Unknown$0 to Unknown
Costs – DMH – loss of training sites
(§191.1795) p.3
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
Cost Increase – OA (§191.1802) –
Potential increase in transfer to LEF p.4
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET EFFECT ON
THE GENERAL REVENUE FUND
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
OTHER STATE FUNDSCost Increase – OA (§191.1802) –
Potential increase in transfer to LEF p.4
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET EFFECT ON
OTHER STATE FUNDS
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
LEGAL EXPENSE FUND (0692)Transfer-in – Increase in appropriation
from General Revenue (§191.1802) p.4$0 to Unknown$0 to Unknown$0 to Unknown
Cost Increase – OA (§191.1802) –
Potential increase in transfer to LEF p.4
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET EFFECT ON
THE LEGAL EXPENSE FUND$0$0$0 L.R. No. 1261H.01I
Bill No. HB 489
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FISCAL IMPACT – State GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026COLLEGES AND UNIVERSITIESCost Increase – Increase in LEF
payouts (§191.1802) p.4
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET EFFECT ON
COLLEGES AND UNIVERSITIES
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
FEDERAL FUNDSLoss – DMH (§191.1800) – Reduction
in federal funds for loss of accreditation
p.3-4
$0 to
(Unknown,
potentially
significant)
$0 to
(Unknown,
potentially
significant)
$0 to
(Unknown,
potentially
significant)
ESTIMATED NET EFFECT ON
FEDERAL FUNDS
$0 to
(Unknown,
potentially
significant)
$0 to
(Unknown,
potentially
significant)
$0 to
(Unknown,
potentially
significant)
FISCAL IMPACT – Local GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026LOCAL GOVENMENTSCost Increase – Increase in legal
payouts (§191.1802) p.4
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATE NET EFFECT ON
LOCAL GOVERNMENTS$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown) L.R. No. 1261H.01I
Bill No. HB 489
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FISCAL IMPACT – Small Business
This proposal could directly impact small business health care providers. (§§191.1770 to
191.1810)
FISCAL DESCRIPTION
This bill establishes the "Do No Harm Act" and provides terms and definitions relating to
"academic standards", "health care related academic programs", "medical institutions of higher
education" and "Diversity-Equity-Inclusion" or "DEI" among others.
CERTIFICATION AN TRANSPARENCY (Section 191.1780) The bill requires medical
institutions of higher education to submit an annual certification by December 31st to the State
Board of Registration for Healing Arts, within the Department of Commerce and Insurance, and
the coordinating Board of Higher Education, within the Department of Higher Education, that
the institution does not require applicants or students to subscribe to DEI ideologies. This bill
requires medical institutions of higher education to publish titles and syllabi for all mandatory
courses, seminars, classes and trainings on a public online database, and prohibits institutions
from conducting DEI audits or hiring DEI consultants.
ASSESSMENTS AND STANDARDS (Section 191.1785) The bill requires medical institutions
of higher education to require applicants to complete a standardized admissions test and outlines
academic standards for health care related courses of study, as specified in the bill. If a medical
institution of higher education wants to alter the standards for admissions, the new standards
must be submitted to either chamber of the General Assembly and shall not be effective until at
least 60 days have passed during which a joint resolution of disapproval may be passed by both
chambers and approved by the Governor to invalidate any such submitted standards.
HEALTH CARE-RELATED DEI PROVISIONS (191.1790-191.1810) The bill restricts health
care-related professional licensing boards from any having any requirements for obtaining or
renewing licenses be associated with DEI related materials or programs. State-required health
care-related professional certifications shall not use DEI material or require DEI training as part
of the certification process. Such boards and organizations are prohibited from conducting DEI
audits or hiring DEI consultants.
Health care providers and medical institutions of higher education are prohibited from receiving
state contracts or grants without certifying that the provider or institution will not require
specified individuals from subscribing to, studying, or receiving instruction on DEI material.
Such providers and institutions must submit annual certification attesting to their compliance. All
state entities applying for any federal health care related grant relating to DEI shall publish on a
public website all materials, requirements, and instructions relating to the grant application along
with a copy of the grant proposal to the State Board of Registration for the Healing Arts and to
the members of the House and Senate Committees on Health Policy. L.R. No. 1261H.01I
Bill No. HB 489
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The bill provides any aggrieved person a cause of action for any violations of these sections to
include declaratory and injunctive relief, damages of at least $100,000 against the health care
provider or medical institution of higher education for any violations, compensatory damages,
and costs and attorney fees. Further the bill waives sovereign immunity for such providers and
institutions for up to a year after any violation.
The bill requires health care providers with more than 50 employees or any medical institution of
higher education to annually submit certification of compliance to the State Board of
Registration for the Healing Arts with Sections 191.1770 to 191.1810, RSMo, and authorizes the
Attorney General to investigate allegations of violations. In addition to any relief granted under a
private right to action, the Attorney General may seek civil penalties up to $1,000,000 against a
health care provider or medical institution of higher education for each violation of sections
191.1770 to 191.1810.
The State Board of Registration for the Healing Arts shall publish on its website annually a list
of all the health care providers and medical institutions that have provided annual certification.
This legislation is not federally mandated, would not duplicate any other program and would not
require additional capital improvements or rental space. L.R. No. 1261H.01I
Bill No. HB 489
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SOURCES OF INFORMATION
Attorney General’s Office
Department of Commerce and Insurance
Department of Elementary and Secondary Education
Department of Higher Education and Workforce Development
Department of Health and Senior Services
Department of Mental Health
Department of Social Services
Office of Administration
Office of the Secretary of State
Northwest Missouri State University
University of Central Missouri
St. Charles Community College
Office of the Governor
Missouri House of Representatives
Joint Committee on Administrative Rules
Missouri Senate
Missouri Office of Prosecution Services
Office of the State Courts Administrator
Julie MorffRoss StropeDirectorAssistant DirectorMarch 3, 2023March 3, 2023