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Missouri Supreme Court Backs ACA Medicaid Expansion

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What You Need to Know

  • Missouri has provided no Medicaid coverage for able-bodied, childless, working-age adults.
  • In August 2020, voters added a Medicaid expansion requirement to the Missouri Constitution.
  • The state General Assembly refused to provide the funding to implement the requirement.

The Missouri Supreme Court ruled unanimously Thursday that state lawmakers must come up with the cash to expand eligibility for Missouri’s Medicaid program.

The court sent the case, Stephanie Doyle et al. v. Jennifer Tidball et al. (Missouri Supreme Court Case SC99185), back to a state court judge in Cole County, Missouri, and told him to develop a judgment that will meet the needs of people who could benefit if Missouri expands its Medicaid program.

Missouri residents voted in August 2020, by a 53% to 47% margin, to add a Medicaid eligibility expansion amendment to the Missouri Constitution. Implementing the measure would help the state qualify to participate in the federal Affordable Care Act Medicaid expansion funding program.

However, state lawmakers have refused to fund implementation of the measure. Judge Jon Betem, who heard the Doyle case in Cole County, ruled that one part of the Missouri Constitution prohibits voters from using a ballot measure to force lawmakers to appropriate funding for a program, unless the measure provides a mechanism for raising revenue to cover the cost of the appropriation.

Missouri Supremes’ Decision

The Missouri Supreme Court held — in a “per curiam” opinion, or an opinion authored by all judges on the court — that the new Medicaid expansion amendment simply affects how the state Medicaid program allocates its funding, not lawmakers’ decisions about appropriations.

The new Medicaid expansion amendment does not require state lawmakers to “authorize the expenditure and disbursement of a specific amount of money for a specified purpose,” the court said.

Lawmakers may not appropriate enough money to support the Missouri Medicaid program, but the legal consequences of inadequate Medicaid funding appropriations are not relevant to the Doyle case, according to the court.

Seven judges serve on the Missouri Supreme Court. Three were appointed by Democrats, and four were appointed by Republicans.

One of the judges was appointed by Missouri’s governor, Mike Parson, who has opposed the Medicaid eligibility expansion effort.

ACA Medicaid Expansion Background

Medicaid is a program that uses state and federal money to pay for health care and nursing home care for low-income people, and for some moderate-income people who qualify for nursing home benefits under state eligibility laws.

About 859,000 of Missouri’s 6.1 million residents had Medicaid coverage in April 2020, according to

The current Missouri Medicaid program provides no coverage for able-bodied, childless, working-age adults.

The Affordable Care Act provides extra federal funding for states that make Medicaid coverage available to all adults with income up to 138% of the federal poverty level, or about $17,774 per year for a single person living in Missouri.

Analysts at the Henry J. Kaiser Family Foundation have predicted that putting Missouri in the ACA Medicaid expansion program would help about 127,000 low-income, childless, uninsured adults get health coverage.

If Missouri expands Medicaid, it may have to increase spending by $310 million, and it may get about $1.15 billion in additional federal funding, according to the Kaiser Family Foundation analysts.

Missouri lawmakers approved a $35 billion fiscal year 2022 budget in May. The budget calls for the state to spend about $10.7 billion on Medicaid and a related program, the Children’s Health Insurance Program (CHIP). About $1.6 billion of the Medicaid funding would come from state general funds, $5.8 billion from the federal government, and $3.2 billion from other sources.

What It Means

Advocates for Medicaid expansion argue that it can save people’s lives, by giving people better access to checkups and routine sick care.

For health insurers, including Centene Corp. — a giant carrier based in Clayton, Missouri — managing Medicaid and CHIP plans for states represents a large and growing business opportunity.

Hospitals see Medicaid expansion as a way to reduce the cost of uncompensated care. Hospitals have noted that, in many cases, they have a legal obligation to provide care, regardless of patients’ ability to pay for the care.

Some critics have argued, however, that poorly designed expansion efforts could end up reducing the quality of coverage for disabled people and low-income children

For agents and brokers in Missouri, Medicaid expansion coverage could help hold down the cost of commercial coverage.

This would happen by reducing the incentives doctors and hospitals in the state now have to push commercial health insurers and self-funded employer health plans to pay enough to make up for providers’ losses on uncompensated care.

The St. Louis Arch (Photo: STLJB/Shutterstock)


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