On July 22, the Missouri Supreme Court in a 7-0 decision ruled that Missouri’s voter-passed Medicaid expansion must proceed regardless of legislative foot-dragging and inaction by the  Governor. The unanimous decision was decided on fairly simple legal grounds. The court noted that the voter-passed initiative had changed Missouri law and added the parents and other adults in the expansion group into the Missouri Medicaid program. The back and forth in the recent Missouri state legislative session around how much money the Medicaid program needed to cover the expansion group was thus no more relevant to the court decision than any other legislative debate over financing – the law was already changed by the voters to include the expansion group.  The legislature can choose whether to fund the Missouri Medicaid program the court explained, but once it chooses to fund the Medicaid program, it cannot change the voter-passed initiative that requires Medicaid to include parents and other adults in the expansion group.  From the decision:

“The General Assembly chose to appropriate funds for the MO HealthNet programs for FY 2022. This was one of presumably thousands of difficult decisions made each year during the appropriation process. But, having made this decision, DSS and MO HealthNet are bound by article IV, section 36(c) concerning which individuals are eligible to enroll when it spends the appropriated funds. Consequently, DSS has appropriation authority to provide services for all individuals eligible for MO HealthNet, including individuals eligible for coverage and services pursuant to article IV, section 36(c).”

Estimates are that Missouri’s expansion will mean affordable health care to nearly 275,000 people. As Joel Ferber of Legal Services of Eastern Missouri, who worked on the Medicaid expansion case recently noted, “The reality is a lot of these low-wage jobs don’t provide health insurance. This is going to be a way for these low-income folks who want to work to get coverage.” The timeline for people to actually start getting coverage is fairly short, with most experts interviewed in a recent comprehensive overview of the current expansion debate by St Louis Public Radio reporter Jason Rosenbaum expecting action within weeks to move forward.

In addition, observers have described a few outside factors that may have influenced the Court’s thinking here.  Medicaid financing in Missouri, as in most states, makes up a substantial part of the state budget, is targeted at helping lower-income people, a group that usually does not include large political donors, and is thus subject to perhaps more debate and change than many other parts of the state budget.  Missouri reporter Phil Brooks recently noted the checkered history of Medicaid financing in Missouri and how Missouri legislators have “made Medicaid health care providers into lending facilities for the state.” He was referring to the state legislative habit of delaying Medicaid health provider payments for services already performed in order to plug budget holes in other areas. The equivalent for a low-income family in a state that hasn’t expanded Medicaid would be trying to delay paying the landlord your rent in order to send a payment to the hospital for your last giant medical bill for an ER visit. The answer for the family – and the state – is to adequately fund health care services rather than trying to shift money around without dealing with the problem. The Missouri legislature’s history of shifting Medicaid money around instead of adequately funding the program shows that current decisions regarding program funding have less to do with complying with the law expanding Medicaid and more to do with the usual budget process.

Another outside factor in the Missouri debate concerns the substantial extra federal payments under current federal law that will be paid to the state as the expansion becomes operational. Totaling about $1.15 billion over the next two years, these huge additional payments will more than offset any state budget appropriation for expansion and allow the state to tackle many other priorities. It’s harder to argue budget hardship when the state is looking at over a billion dollars in extra payments provided through the American Rescue Plan Act because voters passed Medicaid expansion.

After much debate, this unanimous Missouri Supreme Court decision means voter-passed Medicaid expansion will move forward in Missouri. That’s good news for all the parents and other adults waiting for comprehensive, affordable coverage.