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story.lead_photo.caption Judge Jon Beetem is seen looking at a Powerpoint program shown on a large television screen during Monday's hearing in his Cole County courtroom. Litigants representing both sides in the hearing made their presentations regarding Medicaid funding before Beetem in an afternoon hearing that was rescheduled from Friday. Photo by Julie Smith / News Tribune.

Document: Ruling in Stephanie Doyle, et al., v. Jennifer Tidball, et al.

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The push to expand Medicaid eligibility in Missouri was dealt another blow Wednesday, as a Cole County judge ruled the voter-approved initiative was unconstitutional because it didn't include a way to pay for 275,000 new enrollees.

Plaintiffs, which include three people who would have been eligible for Medicaid on July 1 if expansion were implemented, are expected to appeal the decision.

Cole County Circuit Court Judge Jon Beetem wrote that the state's Constitution is clear that an initiative petition can only spend or appropriate revenue specifically raised in the initiative.

"If the court allows them to spend other state revenues by initiative," he wrote, "such action would deprive the General Assembly of its constitutional right to appropriate revenues in all other non-initiative circumstances."

By expanding the population that is eligible for Medicaid, he wrote, the initiative indirectly requires an appropriation of revenue, and therefore is unconstitutional.

Under the terms of the Medicaid expansion initiative petition, approved by voters in August 2020, adults aged 19-64 would become eligible for Medicaid if their household incomes are 138 percent of the federal poverty guideline or less.

That is $17,774 a year for a single person, equal to working about 33 hours a week at the state minimum wage of $10.30 per hour. For a household of four, the limit is $36,570, the income of one person working full at $17.58 an hour or two people working a combined 68 hours a week at minimum wage.

Under the current Medicaid system, no adult without children is eligible unless they have a qualifying condition such as a disability. Adults with children are eligible if their household income is less than about 16 percent of the federal poverty guideline.

Missouri taxpayers cover about 35 percent of the costs for the traditional Medicaid system. The expansion group would receive coverage under the terms of the Affordable Care Act, which requires states to pay only 10 percent of the cost.

Amendment 2 directed the state to start coverage July 1 and take all the preliminary steps necessary to provide benefits on that date. When lawmakers refused to appropriate the $1.9 billion, including $130 million in general revenue, sought by Gov. Mike Parson to pay for the coverage, the state withdrew a plan amendment submitted earlier this year to federal regulators.

This article was updated at 2:50 p.m. June 23, 2021, with additional details.

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