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story.lead_photo.caption Tim Bommel/Missouri House of RepresentativesJefferson City state representatives, Rudy Veit, left, and Dave Griffith, speak Friday during the final day of the Missouri Legislature’s 101st General Assembly.

Missouri lawmakers are going to leave the final decision over voters' decision to expand Medicaid to "the building across the street."

Courts are likely to decide the fate of Missouri Medicaid expansion.

Gov. Mike Parson included funding for expansion of the program in his proposed budget this year. And he later turned in documentation (a State Plan Amendment) to the federal Centers for Medicare and Medicaid Services, detailing how Missouri would expand its existing program.

The actions gave supporters of expansion hope the executive branch would back them.

But, the General Assembly on May 7 passed a state budget that didn't include funding for Medicaid expansion.

On Thursday, less than a week after the General Assembly passed its budget, Parson sent a letter to the Centers, announcing his withdrawal of amendments to the state's Medicaid plan.

Although he never supported expansion, Parson wrote in a news release, he held that he would always uphold it if passed. But, because the General Assembly didn't include funds for expansion in the 2021 budget, he was forced to withdraw expansion plans from feds, Parson wrote.

He pointed out that prior to the initiative passing, the Missouri Court of Appeals found, as it was written, if passed, "the General Assembly retained discretionary authority to fund or not fund MO HealthNet expansion."

"I'm furious and sad for Missourians. I feel like he lied to us all," Rep. Peter Merideth, D-St. Louis, said.

The reasoning Republican leaders in the General Assembly gave for not including funding for expansion, they said, was that the voter initiative did not include a funding mechanism in its wording.

In August, voters elected to expand the program (with more than 53 percent of voters supporting it) to include adults making 130-138 percent of the poverty level. Officials estimate expansion will cover about 275,000 low-income Missourians.

Expansion would add about $1.9 billion to the cost of the state's program (which was already about $10.8 billion). However, only about $2.7 billion was to come out of Missouri's General Revenue per the governor's proposed budget.

The state uses about $2.3 billion annually, collected from hospitals, nursing facilities, ambulances and other health care providers, to pay a portion of its Medicaid commitment. But, for the first time in 30 years, the General Assembly didn't renew its Provider Tax, which is set to expire in September.

Revenue is likely to fall short soon after the new fiscal year begins, and a special session is anticipated.

The federal government was essentially set to pay all of the cost for Medicaid expansion, at least for the first two years, said Brian Kinkade, the Missouri Hospital Association's vice president of children's health care and Medicaid advocacy.

If you really get down into the weeds, the state is paying first and reimburses itself from money provided by the federal government. The state pays the bill but has a letter of credit with the federal government over the costs they expect from that program.

State Sen. Mike Bernskoetter, R-Jefferson City, said he did not vote to fund Medicaid expansion because every county in his district opposed expansion.

"While we have money to fund it this year, it is borrowed money," Bernskoetter said. "When the federal funds dry up, I believe we will have a large number of people making a living wage that will then be entitled to something we can't afford."

The American Rescue Plan Act, signed in mid-March, contains incentives for the 12 mostly conservative states that haven't yet expanded their Medicaid systems, Merideth said.

"The feds, again, are giving us additional money — $1.2 billion," he said. "That's money we only get if we are a new expansion state. It is a perk they are giving right now."

Each expansion state can receive a 5 percent increase in their regular federal matching rate of 90 percent for two years after expansion takes effect, according to the KFF (formerly the Kaiser Family Foundation).

A lawsuit is inevitable, both sides of the aisle agree.

House Minority Leader Rep. Crystal Quade, D-Springfield, said by backtracking on implementation of expansion, Parson has broken his word.

"Medicaid expansion will still happen as the constitution requires," she said, "but because of the governor's dishonorable action, it will take a court order to do it."

Rep. Sara Walsh, R-Ashland, said she supports the governor pulling back on expansion.

Walsh, a House Budget Committee member and the chairwoman of the Subcommittee on Appropriations for Public Safety, Corrections, Transportation and Revenue, said backing away from expansion is "the right thing to do until funding is lawfully appropriated for the enormous expenses related to Medicaid expansion."

Supporters of expansion ask the General Assembly to ignore a requirement in the constitution that initiatives include an appropriation for funding, she said.

Freshman Rep. Willard Haley, R-Eldon, said he wasn't even aware not funding Medicaid expansion was a option, but having learned more about demands on the budget, he agrees with Parson's decision to rescind amendments to the state's Medicaid program.

Not funding Medicaid isn't an option, Merideth said, and added the decision is going to cause the issue to end up in the courts.

The Missouri Foundation for Health joined a number of health care advocates Friday, when it expressed its disappointment and argued Missourians have a constitutional right to health care through Medicaid expansion.

"The state's failure to move forward with Medicaid expansion enrollment in July will delay access to health care to the Missourians who have waited for it for far to long," wrote Daniel Waxler, the foundation senior communications strategist, in an email to the News Tribune. "Every day this process is delayed is another day nearly 250,000 Missourians will go without access to the health care they need to stay healthy, remain in the workforce, and support their families."

A Missouri region-by-region breakdown of who could be newly eligible may be found at public.tableau.com, he pointed out.

The data shows about 5.3 percent more of the population in the region that contains Cole County qualifies for Medicaid under the expanded rules.

Expansion will create 16,000 jobs and help keep rural hospitals and clinics open, Waxler pointed out.

Part of Missouri's population needs Medicaid, Rep. Dave Griffith, R-Jefferson City, said.

"Health care for all? I don't believe that that is the answer," he continued.

Medicaid in Missouri already costs more than $10 billion annually, he said. And, even though the state has money enough to expand now, Griffith said what happens five years from now worries him.

Griffith worries, he said, the state will have to cut good social programs because of shortages.

Having the issue come up in the August election was a strategic move for Parson, he said.

Some thought Republicans would get the results they wanted in an election with smaller participation, Griffith said.

"That wasn't the case," he added. "Do I think we're going to be sued? Probably."

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