A proposed constitutional amendment has the potential to gut Missouri's Medicaid expansion, reversing what was passed by voters in 2020 and bringing back the legislative control that conservative Republicans want.
Introduced by House Budget Committee Chairman Cody Smith, R-Carthage, HJR 117 would amend the state's constitution to allow the Medicaid expansion program to be subject to annual funding appropriations made by the Missouri General Assembly.
Smith's proposed constitutional amendment would give the General Assembly the power to appropriate money each year to fund Medicaid expansion at the levels that it sees fit. If no funding is approved, then there would be no funding for the program, according to the amendment.
Through a ballot initiative, Missouri voters approved Medicaid expansion in August 2020. It opened the health care program up to those 19-64 years old who make up to 138 percent of the federal poverty level. For a family of three, that is $31,781.
A long road to coverage
Prior to expansion, Missouri had some of the strictest Medicaid eligibility requirements in the nation for working-age adults, according to a study by the Kaiser Family Foundation.
Nondisabled childless adults, regardless of how low their income was, were not eligible before expansion. Only those who were elderly, severely disabled or had children qualified. Parents had to make less than 21 percent of the federal poverty level to qualify, which for a family of three is the equivalent of $4,836 today. Only Alabama and Texas had lower income limits.
These strict requirements created a gap in coverage for those who didn't qualify for Medicaid but also didn't make enough money to purchase private insurance -- a gap that affected an estimated 250,000 Missourians. With expansion, those Missourians were able to apply for coverage, with 90 percent of the program's costs covered by the federal government. The state makes up the other 10 percent.
Reversing expansion or managing budget?
While the House Budget Committee approved the amendment Monday, Democrats have spoken strongly against it. Rep. Peter Merideth, D-St. Louis, said the amendment is an attempt to reverse the will of Missourians.
"It makes me angry, and it makes me tired," Merideth said. "Every step of the way, (Republicans are) just trying to fight against the people and against everybody, against common sense."
Last year, conservative Republicans blocked efforts to fund Medicaid expansion, and Gov. Mike Parson decided not to implement the program because of the lack of funding.
The issue made it all the way to the Missouri Supreme Court, which ruled because the ballot initiative made Medicaid expansion a part of the Missouri constitution, a lack of appropriated money did not mean the program could be halted.
For Smith's amendment to become law, it would have to go on the ballot for a statewide vote. However, if it were to pass, it would cancel out the court's decision and allow a potential lack of appropriations to leave many Missourians without health care coverage.
Smith, who opposed Medicaid expansion, said one of the reasons he proposed this amendment was to allow the Legislature to better manage Medicaid spending, which makes up the largest portion of Missouri's budget, including federal funding.
"Our Medicaid program has grown exponentially over the last several years and the cost has really outpaced even the number of people on the program," he said. "Eventually, it could grow into a size that crowds out other things like public education, public safety, transportation, infrastructure -- all of the other priorities in the state budget.
"If we don't add some cost-control measures -- some reforms to the program -- now, my concern is that it will grow prohibitively expensive in the future."
While the amendment does not overtly say it reverses Medicaid expansion or would give the Legislature the power to do so, Merideth said the wording is deceptive.
"The way they word it, you can't even tell it's about expansion," he said. "It's just this wonky legal language about, 'Shall eligibility be determined by the legislature during the appropriation process?' Well, I don't think people even know from that language that they're saying, 'Can the legislature undo expansion?' Because that's a question that they already voted on."
Sidney Watson, a professor at the Saint Louis University Center for Health Law Studies, agreed by making the program subject to appropriation, the amendment is essentially a rollback of Medicaid expansion.
"That's very different than having a right to coverage," she said, describing how the law currently stands.
Smith said his goal is to manage Medicaid funding through the appropriations process.
"And that doesn't mean that we won't have Medicaid expansion necessarily," he said. "It just means that it's a budgetary function and (a) decision, ultimately, of future General Assemblies as to whether or not they want to appropriate for those parts of the program."
Along with subjecting Medicaid expansion to appropriations, Smith's amendment would also implement a work requirement. Missourians who are a part of the Medicaid expansion population -- those aged 19-64 who make less than 138 percent of the federal poverty level -- would need to work or have some work equivalent such as education, volunteer work, substance abuse treatment or actively searching for a job.
While the idea of a work requirement may appear to be a simple qualification, it comes with both logistical and legal complications.
If states want to customize their Medicaid programs such as adding work requirements, they must submit what is known as an 1115 waiver to the federal government for approval. And during the Trump administration, some states began implementing work requirements as part of the eligibility qualifications for Medicaid.
One of the problems with a work requirement is that it forces people to submit paperwork and forms to prove they are working. If they fail to do so, they are kicked out of the program.
"Most people are working but once you make the requirement and people have to jump through a bunch of hoops and they have to prove how many hours they work, and for a lot of people, it's really burdensome," Watson said. "It gets really confusing."
In 2018, Arkansas was the first state to implement a work requirement for its Medicaid expansion group, and it resulted in about 18,000 residents losing coverage in the first seven months, according to the Center for Budget and Policy Priorities. Every month, about 75 percent of those required to report hours didn't.
Arkansas' work requirement and that of four other states have been struck down in federal courts for violating the objective of Medicaid.
The Biden administration announced in February 2021 it would remove all waivers the government had previously granted under the Trump administration, and it has yet to approve any new waivers.
If Smith's amendment passes with the work requirement, then a legal issue could arise. The work requirement would be a part of Missouri's constitution, but the requirement could not go into effect without the federal waivers that the federal government is not approving.
Rep. Sarah Unsicker, D-Shrewsbury, is the Democratic Caucus policy chair and a member of the House Subcommittee on Health Care Reform. She said this conflict in the law could potentially gum up the entirety of Missouri's Medicaid program.
"It would block up our entire Medicaid program because work requirements would still be in the constitution, so we would have to do them because that's what the constitution says," she said. "But (the Centers for Medicare & Medicaid Services) wouldn't authorize it, so they wouldn't give us the federal Medicaid match."
That would leave Missouri on the hook for the 90 percent of the Medicaid budget funded by the federal government, Unsicker said.
Watson said if this amendment passes with the work requirement, there will be legal challenges.
"I will also predict that the Biden administration 100 percent will not approve a work requirement, and that is going to be part of what pushes this into litigation," she said.
The work of the Missouri News Network is written by Missouri School of Journalism students and editors for publication by Missouri Press Association member newspapers.
HJR 1117: Medicaid eligibility, requirements
Rep. Cody Smith