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In-depth: Courts now must resolve Missouri’s Medicaid expansion fight

Posted at 7:06 PM, Jun 17, 2021
and last updated 2021-06-17 20:06:01-04

KANSAS CITY, Mo. — The courts will decide the fate of Medicaid expansion in Missouri, which voters passed last summer. It is slated to expand July 1.

The GOP-dominated state legislature chose not to provide funding for it during the recently concluded session — a decision Rep. Patty Lewis, a Democrat from Kansas City, called “a destruction of the will of the electorate.”

Gov. Mike Parson, who initially proposed $130 million in state revenue for expansion in his 2021-22 fiscal year budget, announced earlier this month that he wouldn’t let newly eligible residents sign up for MO HealthNet without funding.

That leaves it up to the courts to enforce Missouri’s constitution.

“I’ve had a lot of people talk to me and talk about (how) they didn’t want to expand Medicaid.” Sen. Mike Cierpiot, a Republican from Lee’s Summit, said Wednesday. “In my mind, that question’s been answered. The ballot thing last year expanded Medicaid to [make] these new people eligible, mostly the working poor. So now the question is, are we going to fund it? Some of my party thinks that the courts will throw it out; I’m of a different opinion.”

Some Republican state legislators — including Rep. Chris Sander, a Republican from Cass County who represents the 33rd District — claim that Medicaid expansion is unconstitutional, because the ballot language didn’t include a funding source.

Cierpiot disagreed.

“I think the courts will rule fairly quickly," he said. "I could be wrong, but I think they will say the ballot language was pretty clear... It’s not a new program. It’s just a change of an existing program, so, if I’m right and the courts then say we’re going to start signing people up, they’ll start signing people up.”

Three Missouri residents who would be covered by expanded access to the federal health insurance program for the poor have sued, hoping to force the state to enroll those eligible under Missouri Amendment 2.

“Medicaid expansion was supposed to target the working poor,” said Rep. Wes Rogers, a Democrat from Kansas City, representing Clay County. “Many of the folks who will be hurt by this the worst are low-income workers doing their best to get by.”

The next hearing in the case was scheduled for Friday in Cole County courtroom, but had to be moved to 1 p.m. on Monday after President Biden declared Juneteenth a federal holiday. It will be observed Friday, since Juneteenth occurs on Saturday this year.

Who’s covered and at what cost?

Amendment 2, which passed by a more than 6% margin statewide, expands Medicaid coverage to adults 19 to 65, who make $17,608 or less per year. The income limit for a four-person household is $36,156.

Thinking about the population of people that expansion will cover, these are folks that are working at least 40 hours a week. They are working a full-time job, but they are working at your local restaurant, your local fast-food restaurant, your dry cleaner for employers who either can’t or aren’t offering health care.

Yet, these folks aren’t making enough to go out and buy their own on the free market, so these are folks that are doing everything that we say we want them to do. They are working hard, they are trying to make a better life, and this is a way of providing them with health insurance to make sure that they and their families can take care of themselves when they get sick.
Sen. Greg Razer (D-Kansas City), Missouri’s 7th District

Missouri administers its Medicaid program through MO HealthNet, which is expected to add up to 275,000 state residents if courts uphold the amendment.

Cierpiot said the legislature’s job is to pass a budget, not the courts, and noted that Parson’s initial budget proposal in January included more than $1.9 billion in funding for Medicaid expansion.

Most of that, roughly $1.65 billion, comes from the federal government.

“These are taxes that Missourians have been sending to the federal government for years,” said Sen. Greg Razer, a Democrat from Kansas City who represents the 8th District. “They have been going to other states. Now, we’re saying, let’s bring that money home and take care of our own citizens.”

Timeline of Medicaid expansion

The federal government expanded Medicaid in 2014 as part of the Affordable Care Act, which the Supreme Court upheld in a separate ruling Thursday morning.

During the first year, 26 states and the District of Columbia adopted and implemented Medicaid expansion.

Five more states joined during the next two years, before another wave of five states signed up beginning in 2019.

Voters in Missouri and Oklahoma approved Medicaid expansion at the ballot box last summer. Oklahoma’s expansion also is set to begin July 1.

Kansas remains one of 12 states, mostly concentrated in the South, that have yet to adopt Medicaid expansion.

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Importantly, as Rep. Wes Rogers, a Democrat from Clay County, pointed out, no states that have expanded Medicaid have subsequently reversed course and withdrawn from the program. That includes GOP strongholds like Kentucky and Arkansas, which adopted and implemented Medicaid expansion in 2014, and Montana, which expanded Medicaid in 2016.

Cierpiot, who historically has not supported Medicaid expansion, is part of a small number of Republicans who broke party ranks to support funding expansion.

He said the fact that 54% of his district supported Amendment 2 and his view that fulfilling budgetary obligations is the responsibility of the legislature informed his decision.

Instead, the Missouri House Budget Committee voted down House Bill 20 on March 25 and the Missouri Senate followed suit a month later, setting up the legal challenge in Cole County Circuit Court.

Benefits of expansion

Academic studies overwhelmingly have shown multiple benefits for states that adopted Medicaid expansion.

That includes a sharp drop in the number of uninsured poor, better access to health care, improvements in insurance rates for rural and minority residents, more jobs, state budget and revenue gains, and other benefits in states that expanded Medicaid, according to analysis from the Kaiser Family Foundation.

“Whether you look at this from an economic standpoint or just a humanity standpoint, this is the right thing to do,” Razer said.

Several Democratic lawmakers from the Kansas City area highlighted Medicaid expansion as a job creator for Missouri.

Reps. Ashley Aune, a Democrat from Kansas City, representing Clay and Platte counties; Rogers and Robert Sauls, a Democrat from Independence, representing Jackson County, all noted that Medicaid expansion is expected to create as many 81,000 jobs in the state during the next five years, many concentrated in rural areas.

Lewis, who is the only registered nurse in the Missouri General Assembly, said Medicaid expansion should help ease the burden on the state’s health care system by helping the working poor be more proactive about their health.

“When I worked in the ICU, I took care of many patients who were admitted to the hospital because they did not have access to preventive health care services or have health care coverage,” Lewis said. “Instead of having access to care to keep them healthy, they ended up in the hospital, unable to work, unable to earn an income thus putting them further and further behind financially. This issue is personal. Lives are on the line.”

That is especially true in rural areas of Missouri, where clinics and hospitals have closed at alarming rates in recent years.

“Absolutely, this will help ...,” Cierpiot said. “It’s the rural clinics, the Truman Medical Centers, places like that that have a really high uninsured population that are going to benefit a lot. They’ve closed several clinics in the rural areas. There is a quiet crisis out there that, hopefully, if we get this resolved, will be fixed.”

Despite the growing health care access issues, most of the resistance to Medicaid expansion originates in rural Missouri.

“If you look at it, rural Missouri did not support Medicaid expansion, which is kind of curious because those areas will benefit probably as much as any because there’s so many uninsured in those areas,” Cierpiot said.

Opposition to expansion

The primary argument raised against expansion centers around the cost, but Democratic leaders also rejected concerns about Medicaid expansion’s price tag, noting that most states are more solvent after expanding their programs because the federal/state split for new enrollees is much higher than for existing participants.

“There is more than enough money in the budget to implement expansion; Missouri would receive $1.4 billion in matching dollars from the federal government and an additional $1.2 billion over two years included in President Joe Biden’s American Rescue Plan,” said Sen. Lauren Arthur, a Democrat from Clay County. “It would be fiscally irresponsible and in violation of the constitution to continue blocking health care access for working families."

Cierpiot said that Missouri is set to receive an additional $50 million per month for the next two years — the $1.2 billion Arthur also referenced — but shrugged off worries that MO HealthNet would run out of money.

He said supplemental appropriations are common, especially for Medicaid amid fluctuating drug prices or other factors, and that process could be used if funding starts to run out.

“There just is no good argument for not doing it,” Razer said. “Plus, these aren’t state tax dollars. This is federal money that we are already sending to the federal government that is coming back home.”

Democratic lawmakers would have preferred to resolve the funding question during the legislative session rather than kicking the can down the road and inviting expensive legal proceedings on the taxpayer’s dime ahead of the July 1 deadline.

“Rarely are the fiscally and morally responsible options the same," Aune said, "but that is the case here — plain as day... We are going to have to come back and fix this mess, and I hope it's sooner rather than later to mitigate the likely damage this will cause.”