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Missouri Medicaid Expansion Proponents Likely Need Courts To Follow Through On Voter-Approved Plan

medicaid expansion ballot question
Nat Thomas | St. Louis Public Radio

Updated at 4:30 p.m. on Thursday with Parson's comment about Medicaid expansion:

With the Missouri Senate’s decision not to fund Medicaid expansion, proponents of bolstering the health care program are expected to look to Missouri’s courts to follow through on the voter-approved initiative.

In August 2020, voters approved a constitutional amendment that would expand Medicaid to those at 138% of the federal poverty level. For 2020, this was an annual income of $17,600 for an individual and roughly $36,000 for a family of four. Gov. Mike Parson, an opponent of Medicaid expansion, included money to pay for it in his fiscal 2022 budget — which lawmakers have to send to him in the coming days.

But the GOP-led House chose not to include funding for expansion, contending that, among other things, they were worried about the impact of the move on future budgets. The Senate voted 20-14 late Wednesday to defeat Minority Leader John Rizzo’s amendment putting expansion funding in the budget.

Rizzo, D-Independence, predicted that the matter will now be decided by courts, especially since the constitutional amendment specifically states that people who make up to 138% of the federal poverty level “shall receive coverage for the health benefits service package.”

“Every state senator swore an oath to uphold that constitution. By not funding Medicaid expansion, these budget bills violate that oath and are unconstitutional,” Rizzo said. “Funding for Medicaid expansion is now an issue for the courts.”

He said going forward, the more immediate question is what happens on July 1. “Will the governor’s administration enroll eligible Missourians as stated in the constitution, or will state officials block health care for more than 230,000 low-income workers?” Rizzo said.

Parson opposed the Medicaid expansion budget amendment but has said as recently as this week: “I don’t have a district anymore, I have to represent all Missourians, and they voted for it.”

On Thursday afternoon Parson tweeted: "We will assess our options and legal requirements on how to move forward with Medicaid expansion, once the budget is finalized."

Republicans like House Budget Chairman Cody Smith have contended that Medicaid expansion isn’t mandatory, since there wasn’t language in the amendment specifying a funding source. They point to an appellate court decision that allowed Medicaid expansion on the ballot that states it “does not direct or restrict the General Assembly’s ability to change the amount of appropriations for the MO HealthNet program or to increase or decrease funding for the program based on healthcare-related costs.”

“It’s consistent with where we’ve been since the passage of the Affordable Care Act, which has been over 10 years ago,” said Smith, R-Catharge. “The Missouri House and, more broadly, the Missouri General Assembly has rejected Medicaid expansion… over the last 10 years, and that’s where we are today.”

Financial and political consequences

Jim Layton, a former solicitor general for Missouri who has been following the Medicaid expansion fight closely, said there’s a couple of ways the push for expansion could go in the coming days.

Parson’s administration could still let people in the Medicaid expansion join the program. And that would prompt Medicaid to run out of money, which could cause enough political pressure from doctors and hospitals that aren’t getting reimbursed for lawmakers to cover expansion.

“Nothing that we passed in our constitutional amendment says to the legislature that it has to appropriate one dollar more than it used to appropriate,” Layton said. “The legislature can refuse to appropriate any more money than it used to. What the legislature can’t do is change the criteria for qualifying for Medicaid, because that’s now in the constitution.”

Rebecca Woelfel, a spokeswoman for the Missouri Department of Social Services, said her agency's Medicaid division has submitted state plan amendments to the Centers for Medicare and Medicaid Services.

The other possibility is that Parson’s administration refuses to provide access to people in the expansion population. And Layton said that could provide the foundation for a successful lawsuit.

“To me that’s the way it gets set up,” Layton said.

The state says that it doesn’t have the authority to give someone access to Medicaid and that then gets challenged in court, Layton said.

Jeremy Cady, executive director of the Missouri chapter of Americans for Prosperity, which took part in the 2020 lawsuit seeking to keep Medicaid expansion off the ballot, said his group is carefully watching what happens next.

“My assumption is at some point in time, it will likely get back to the court one way or the other," he said. “We’re just going to have to review the method and how it gets there and how it’s handled by the Parson administration.”

Effect on appointing judges

Cady also said that if courts force the legislature’s hand, it could be one of the reasons conservative leaning groups bankroll an initiative to alter the Missouri Nonpartisan Court Plan — the system in which appellate and Supreme Court judges are selected in the state.

“Judicial selection is another one of our priorities at Americans for Prosperity,” Cady said. “I think the courts have made a number of rulings over the past few years that Missourians would take issue with and have trouble with. So I think that list is already there and already growing — and Medicaid expansion could just be another item that we could add to that as far as how the courts are not reflecting the actual populace in Missouri.”

The last attempt to alter the Nonpartisan Court Plan was in 2012, when the legislature placed a measure on the ballot increasing the number of nonlawyers on a panel that sends judicial nominees to the governor. Proponents of that effort decided not to fund a campaign, and it ended up being soundly defeated.

There are budgetary implications for not following through on Medicaid expansion as well.

Missouri would stand to receive more than $1 billion from the federal government as part of the latest coronavirus relief plan. And Medicaid expansion backers note that could pay for the state portion of expansion for years.

But Republicans, like Smith, have said that the money is temporary — and they added that if the state does have to allocate general revenue for the program, it will take away money for other endeavors.

Follow Jason on Twitter: @jrosenbaum

Jason is the politics correspondent for St. Louis Public Radio.