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Nationwide, resistance to Medicaid expansion has crumbled over the years as, one by one, conservative states have joined the ranks of those that have expanded the program's health coverage to low-income adults.

Missouri remains one of only 13 (mostly conservative southern) states that have not expanded their Medicaid programs to include adults earning up to 138 percent of the poverty level.

State Rep. David Griffith, of Jefferson City, and state Rep. Sara Walsh, of Ashland, both Republicans, said they strongly oppose Amendment 2 because the drafters of the amendment didn't include a funding mechanism for the program.

State Rep. Rudy Veit, a Wardsville Republican, said his opinion is people will vote the way they want to vote.

But, Veit warned, "There's a lot of people who don't like to expand any program. Once you expand, it becomes a right (to people), and you can never get rid of it."

Oklahoma was the most recent to opt into Medicaid expansion. Voters passed expansion in that state June 30 with a narrow 6,000-vote margin. It was the fifth state in which voters passed expansion despite opposition by Republican leaders and the first state to expand Medicaid during the COVID-19 pandemic.

If Missouri's Amendment 2 passes Aug. 4, that would make Missouri the 38th state to extend its Medicaid program. The District of Columbia has also expanded Medicaid.

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Missouri Republican lawmakers have opposed expansion, primarily on the grounds adding adults to the program would be too costly. They say the estimated $200 million it would cost annually would be devastating to Missouri's economy.

"There's no funding mechanism," Walsh said. "You can't have a system where you're growing and growing and growing and not expect costs to go up."

However, supporters of the initiative argue the benefits outweigh any costs, and because of investments, job creation and a healthier population, the state stands to save a lot of money by expanding — possibly up to $1 billion.

A successful initiative petition this spring in Missouri got the issue placed on the November ballot. Gov. Mike Parson, a Republican, scheduled the vote for the August primary election, which is not likely to have as great a turnout as the general election.

It is estimated expansion of MO HealthNet, the state's Medicaid program, would add about 230,000 people to its rolls. MO HealthNet already serves about 900,000 people.

On the same day voters elected to expand Medicaid in Oklahoma, lawmakers in Missouri held a hearing on the fiscal note generated for Amendment 2. The state Auditor's Office found the outcome from expansion could range from a cost of $200 million annually to savings of $1 billion.

There are too many unknowns, opponents offered.

Some speakers testified expansion cost their states more money than expected, while others said neighboring states had seen savings.

Jeremy Cady, the Missouri director for Americans for Prosperity, said Tuesday that expanding MO HealthNet could pose challenges to the state. Americans for Prosperity is a conservative/libertarian political action group backed by Charles Koch.

"From our viewpoint, the biggest challenge is the spending that's going to be required to implement it," Cady said. "Oftentimes, the initial amount thrown out there is less than what it ends up being."

It is estimated it will cost $2 billion to expand Medicaid in Missouri. Because the federal government has committed to pay 90 percent of the cost, that leaves about $200 million the state would be responsible for, Cady said.

Other states have ended up paying much more than anticipated, he said. Kentucky, he said, ended up paying about 154 percent more than expected.

That additional money has to come from somewhere, Cady said.

"We're going to have to cut education or (other programs), or we're going to have to raise taxes," he said.

That can be a challenge too because the Hancock Amendment limits how quickly the Legislature can raise taxes without going to voters, Cady said. If the Legislature is to raise taxes to pay for the increased spending, it would have to do so incrementally, he continued.

"Our budget right now is not looking great due to the pandemic," he said. "Missourians haven't shown a willingness to accept a tax increase for several years now."

But Dina van der Zalm, a rural health care expert with the Missouri Rural Crisis Center, said Missouri needs to see expansion through to the end.

"We've watched 37 other states expand, and none have undone it," van der Zalm said. "The false dichotomy of 'Do you want to finance education or pay for Medicaid?' is not realistic."

Arkansas, she said, has saved hundreds of millions of dollars through Medicaid expansion, and it preserves health care jobs in rural communities.

Billions of Missouri tax dollars will return from Washington, D.C., if the state expands Medicaid, said Jack Cardetti, spokesman for the "Yes on 2" campaign to push expansion across the finish line in the state.

"There are lots of people and organizations throughout the state that have endorsed the Amendment 2 campaign," Cardetti continued. "We're one of the few public policy issues that both business leaders from across the state — including the state's largest business organization, the Missouri Chamber of Commerce — and organized labor both are endorsing."

Independent studies have shown annual savings from expansion in the state budget are expected to reach more than $1 billion by 2026, he said.

Medicaid expansion will create more than 16,000 jobs annually, he said.

Most important, supporters say, is expansion will protect rural hospitals and make Missourians healthier. In late June, a coalition of 13 national organizations representing patients with serious chronic medical conditions released a statement supporting expansion. That coalition included the American Cancer Society, Diabetes Association, Heart Association, Kidney Fund and Lung Association, and the Cystic Fibrosis Foundation, Susan G. Komen for the Cure, and others.

Phil Glynn, a board member of the American Heart Association of Greater Kansas City, said Medicaid expansion is about making the state healthier.

"When you look at the coalition that is supporting the passage of Amendment 2," Glynn said, "this is something that business, labor, health care, faith community and political activists all support. This is an issue that unites all voters."

It may unite voters, but it doesn't unite political adversaries.

Medicaid expansion is part of the Affordable Care Act, also known as Obamacare. Originally, states were not given a choice to participate in expansion or not. But, a 2012 federal court decision said the U.S. government could not make participation mandatory.

In 2014, then-Gov. Jay Nixon tried to expand MO HealthNet, but the Republican Legislature didn't comply. The effort led to the arrest of 23 peaceful protesters — mostly religious ministers, now known as the Medicaid 23.

Protests drew people from across the state, trying to draw attention to the plights in their communities, said Rod Chapel, a Jefferson City attorney.

More than 300 demonstrators, led by clergy, rallied in the Capitol Rotunda, then went to the state Senate's upper gallery to urge lawmakers to expand Medicaid assistance to poor Missourians.

Police arrested 23 of the protesters after their singing, praying and chanting was loud enough to force senators to stop their debate because they couldn't hear each other.

Then-Cole County Prosecutor Mark Richardson charged them with trespassing and obstructing government operations, both misdemeanors, and a Cole County jury in 2016 convicted each of the defendants only of trespassing.

Before they could appeal, Nixon offered them pardons.

This is about basic health care for the most disadvantaged, and lawmakers refuse to give it, Chapel said.

"We have an overwhelming amount of support for expansion of Medicaid — from hospital associations to chambers of commerce," Chapel said. "It makes me wonder, 'What are these politicians doing?'"

There isn't an argument among citizens about Medicaid expansion, he said.

"We have a legislative body over there — they have stopped listening to the elective and are tone-deaf. We have to force measures through the initiative process that should have been done through the legislative process."

This article was edited at 10:53 a.m. July 20, 2020, to clarify that Americans for Prosperity is a conservative/libertarian political action group backed by Charles Koch.

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