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The people voted. GOP lawmakers balked. Now a court has cleared the way for Medicaid expansion in Missouri.

The Missouri Supreme Court has cleared the way for Medicaid expansion to go forward there, ruling unanimously Thursday that the state Legislature must fund the new program. The Affordable Care Act program is expected to bring coverage to approximately 275,000 low-income people.

Missouri’s difficult and winding path to Medicaid expansion — voters approved the program last summer, but Republicans in state government refused to proceed with it — demonstrates the challenge Democrats face in bringing the program to the dozen states that do not yet participate.

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Most states led by Democrats adopted the program as soon as it began in 2014, and some states with Republican leadership have joined since then. Still, a dozen states, primarily in the South, do not participate, with Republican officials citing concerns about the cost of expanding coverage and worries that free public insurance could create a disincentive to work. That has shut about 4 million low-income Americans out of the public coverage program.

Missouri is among a half-dozen states that have used voter referendums to join the program, circumventing opposition by state lawmakers or governors by going straight to the ballot box.

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Most of the states that do not have Medicaid expansion also lack a ballot initiative process that would allow voters to decide on the issue, shutting off one of the Democrats’ most successful tactics for growing enrollment in the program.

Democrats in Congress have increasingly been discussing how to bring coverage to that population. They plan to address the issue in the new reconciliation package, which was released last week, but have not yet agreed on a policy to do so.

Some Democrats have suggested building a federal program identical to Medicaid that could step in and cover people in nonparticipating states. Others have proposed working with cities and counties that want to expand coverage, rather than trying to bring entire states on board.

Missouri’s Medicaid expansion ballot initiative passed by a 6-point margin last summer. The measure directed the state to begin expanding Medicaid this July, but this spring the Republican-controlled state Legislature declined to appropriate funds for the program.

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Gov. Mike Parson, a Republican, then said he was unable to implement it.

Groups supporting the Medicaid expansion turned to the courts for relief. A lower court ruled in the state’s favor, finding that the Legislature was not required to appropriate funds for Medicaid expansion. But the ruling from the Missouri Supreme Court reverses that decision.

The court said that the state Medicaid program was bound by the ballot initiative “concerning which individuals are eligible to enroll,” regardless of any appropriation decisions made in the Legislature.

The ruling directs the lower court to work out the details of getting the new program underway, but it is unclear when Missouri will begin enrolling patients. Kelli Jones, a spokesperson for Parson, said in an emailed statement that the governor did not think he had the “necessary budget authority” to implement the expansion and was “looking at what options may be available.”

Because of its timing, Missouri’s participation in Medicaid expansion is actually likely to leave the state better off financially, at least for the next two years. That is because new federal stimulus funds, available to states that expand Medicaid this year, will cover the state’s 10% share of the program — and then some.

The state will receive about $1 billion over two years in additional funds for expanding Medicaid, according to a Kaiser Family Foundation estimate. Last summer, before those funds existed, Missouri’s state auditor had estimated that the Medicaid expansion would cost the state a maximum of $200 million.

Missouri is the second state to receive the new stimulus funds from the American Rescue Program, after Oklahoma, which opened its Medicaid expansion July 1 after it also passed a ballot initiative in 2020. Both states passed their ballot initiatives before those stimulus funds were created.

The Fairness Project, a national nonprofit that helped organize the Medicaid ballot initiative in Missouri and in other states, is aiming to put the issue to a vote in South Dakota in 2022. Groups there are gathering signatures before a September deadline.

It had to abandon a similar effort in Mississippi after that state made significant revisions to its voter referendum process earlier this year.

But the ballot initiative strategy may soon reach its limit. Two more states that have not expanded Medicaid, Wyoming and Florida, allow the issue to be brought to a vote, but each presents unique challenges. Florida, as a large state, would be an expensive place to run a campaign, and Wyoming does not provide strong protections for the initiatives its voters pass.

The other states that have not expanded have no statewide ballot initiative process at all.

“We have no way of helping the folks in Texas,” said Kelly Hall, executive director of the Fairness Project.

Hall said those other states may need the federal intervention that Democrats in Washington are discussing.

“Everybody has to row in the same direction to solve this problem,” she said. “We’ve done our part of the work. I’m always hopeful there will be even bigger and better solutions coming out of D.C.”

c.2021 The New York Times Company

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