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Missouri Supreme Court Revives Medicaid Expansion In The State

medicaid expansion ballot question
Nat Thomas | St. Louis Public Radio
The Missouri Supreme Court has ruled that a 2020 ballot initiative that expanded Medicaid in the state did not violate the law.

Updated at 5:35 p.m. July 22 with additional comments and reactions to Thursday's ruling

An additional 275,000 low-income individuals in Missouri are again eligible for publicly funded health care.

In a unanimous opinion handed down Thursday, the state Supreme Court ruled that a 2020 ballot initiative to expand Medicaid did not require lawmakers to appropriate money, and therefore did not violate state law.

“The General Assembly chose to appropriate funds for the MO HealthNet programs for FY 2022,” the judges wrote in what’s known as a per curiam opinion, or one that is not written by a specific judge.

“This was one of presumably thousands of difficult decisions made each year during the appropriation process. But, having made this decision, DSS and MO HealthNet are bound by article IV, section 36(c) concerning which individuals are eligible to enroll when it spends the appropriated funds. Consequently, DSS has appropriation authority to provide services for all individuals eligible for MO HealthNet, including individuals eligible for coverage and services pursuant to article IV, section 36(c).”

MO HealthNet is the official name for Missouri’s Medicaid program.

In other words, the court said, newly eligible individuals will simply draw from the same pot of money as all other beneficiaries. Lawmakers would then have to decide what to do when the current appropriation runs out.

The decision does not mean newly eligible Missourians can access benefits immediately. Gov. Mike Parson in May withdrew federal paperwork that set up the enrollment process.

Lowell Pearson, one of the attorneys for three women who were seeking access to Medicaid, said the ruling was a total victory for his clients. He said it will be up to Cole County Judge Jon Beetem to decide when people can start to enroll, but he predicted his clients will be enrolled next month.

“On Aug. 4 last year, the voters said, ‘We want these people to get Medicaid,'” Pearson said. “We’re a major step closer to them getting it.”

Parson spokeswoman Kelli Jones said in a statement that “after today’s court decision, the Executive Branch still lacks the necessary budget authority to implement MO HealthNet coverage to the expanded population.”

“We are looking at what options may be available to us to seek additional budget authority and also pursuing legal clarity,” Jones said.

House Minority Leader Crystal Quade took issue with that statement, noting that the court "flat-out says the Department of Social Services has the necessary budget authority to provide MO HealthNet coverage to the expanded population."

"The governor and legislative Republicans have wasted enough time and taxpayer money fighting the will of Missouri voters," Quade, D-Springfield, said in a statement. "It’s well past time they started following it.”

Several legal experts St. Louis Public Radio talked to said that because the Missouri Supreme Court upheld the Medicaid expansion amendment, the state doesn’t have much leeway in terms of giving people in the expansion population access to Medicaid. That means that the legislature will have little choice but to provide more money to the state’s Medicaid program — or risk it running out of money, leading to doctors and health care providers not getting reimbursed.

“If [the legislature] tries going forward to distinguish appropriations between the original class of Medicaid recipients and the constitutionally mandated expanded class, I think they lose,” said Dave Roland, an attorney who was not involved in the case. “And this is one of those issues where I want to reinforce, me saying that doesn’t have anything to do with my feelings about Medicaid expansion represents. When the people ratify an amendment to the constitution, it doesn’t matter what you feel about the policy.”

Pearson said the upshot of the ruling is that provisions in the Medicaid expansion amendment outlining who is eligible “is valid, and the state has to start enrolling people because there was an appropriation sufficient in dollars and in language to immediately enroll the newly eligible people.”

“I don’t think anyone can dispute that,” Pearson said.

The amendment, which passed with 53% of the vote in November, made adults age 19 to 65 eligible for Medicaid if they make up to 138% of the federal poverty level, or about $35,200 for a family of four. It also prohibited the state from enacting work requirements for Medicaid recipients. Currently, few adults who have no dependents are eligible for Medicaid.

A single mother with one child has to make less than $3,000 a year to qualify for Medicaid.

Senate Appropriations Committee Chairman Dan Hegeman said in a statement that he was disappointed by the decision.

“The legal gymnastics employed by the court to get their desired political outcome sets a dangerous precedent and greatly diminishes the power of Missourians’ elected representatives,” said Hegeman, R-Cosby.

Amy Blouin, the president of the Missouri Budget Project, which supports expansion, said in a statement she hoped expansion would be implemented quickly.

“As a result of the Supreme Court’s ruling, Missourians across the state will finally be able to realize the health and economic benefits of Medicaid expansion,” she said.

“State after state has shown that in addition to providing insurance to those eligible, expansion is a fiscal and economic boon to state economies and budgets,” Blouin said. “Not only do states save money on existing health services, but federal funds from expansion create jobs and increase economic activity, generating additional tax revenue to fund the state’s share of expansion.”

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Rachel is the justice correspondent at St. Louis Public Radio.
Jason is the politics correspondent for St. Louis Public Radio.