Our Opinion: The contradictions of Medicaid expansion

Voters in a generally conservative state have picked a majority of Republican lawmakers and a Republican governor to lead them. Yet they've repeatedly rejected key decisions of that conservative leadership in favor of liberal ones.

Voters rejected a right-to-work law and approved a minimum wage hike. On Tuesday, they approved an Obamacare provision to expand Medicaid.

Welcome to Missouri, the schizophrenic state.

So how to rationalize the apparent contradiction? It's actually not that complicated. Missouri has long been of two minds: urban liberals and rural conservatives.

In Tuesday's vote, Cole County rejected Medicaid expansion by more than 60 percent. Area counties that are more rural rejected it even more. Here are the rounded off rejection rates of some area counties: Miller, 73 percent; Morgan, 68 percent; Cooper, 66; Callaway, 61; Osage, 77; and Maries, 74.

In fact, most counties in Missouri rejected Medicaid expansion. But the few areas that favored it carried the vote. In St. Louis, 181,501 (73 percent of voters) said "yes" to Medicaid expansion. In Kansas City, the approval rate was an amazing 88 percent.

Hospitals spent more than $10 million to convince voters to approve the measure, and they'll be big beneficiaries. (Interestingly, it's the rural hospitals that are struggling the most, and it was the rural voters who opposed the measure the most.)

Medicaid expansion means adding more than 230,000 Missourians who qualify for government-subsidized health care. Anyone between 19-65 with an income of up to 138 percent of the federal poverty level will qualify.

The ballot initiative puts Medicaid expansion into the Missouri Constitution rather than as a law. That prevents lawmakers from undoing the measure, but it also prevents them from changing it. Other states where voters have passed Medicaid expansion have tried to add premiums or work requirements, for instance.

Now that voters have spoken, lawmakers will have to answer a question that didn't get much attention during the campaign: How to pay for it.

Missouri has cut hundreds of millions of dollars since the start of the pandemic earlier this year, and it will need to be cut more to meet our state's constitutional requirement to balance the budget.

The federal government, however, is on the hook for the biggest amount of Medicaid expansion, 90 percent. That will add to our nation's fast-growing debt, $26.6 trillion at last count.

In good times and bad times, our nation is deficit spending. It's nice to be able to offer all the government services that we do, but it's simply not sustainable.

News Tribune