A court battle is likely in the state’s future after the Missouri Senate last week voted against paying to expand the state’s Medicaid program, scheduled to roll out July 1 after a majority of the state’s voters approved the constitutional amendment in 2020.
At this stage, it is unclear what will happen this summer as those newly eligible for the program seek coverage.
“As elected officials, we have a responsibility and that is to uphold our oath to the Constitution, but also the will of the people,” State Sen. Brian Williams (D-St. Louis) said.
“So, it's very frustrating and disappointing that we didn't fully fund Medicaid expenditures.”
The Senate voted April 28 after hours of debate. The funding failed to pass, with a vote of 14-20 to reject — four Republicans broke ranks with the rest of their party and voted in favor of funding the expansion.
The Missouri House had previously separated the expansion funding and passed the budget bill without it.
Williams noted that the fate of the expansion is now in the hands of Gov. Mike Parson, as lawmakers are required to present a budget to the governor by Friday, May 7.
Williams said that even though the House and Senate voted to exclude expansion funding, Parson could decide to include funding in the budget. It will then go back to the General Assembly where lawmakers will work on a solution.
Parson has previously said he doesn’t support expanding Medicaid, but he supports funding the expansion because it is the will of the voters.
Robin Rudowitz, Kaiser Family Foundation vice president and co-director for the Program on Medicaid and the Uninsured, said the state of Maine experienced the longest lag between voters approving Medicaid expansion and its implementation. Former Gov. Paul LePage vetoed a $55 million Medicaid expansion bill in June 2018. It was not implemented until January 2019, when new Gov. Janet Mills took over.
“I think Missouri is unique —because the ballot measure was a constitutional amendment and not a state legislative change,” she said.
“There have been a number of states that have adopted the expansion through ballot measure, and it hasn’t always been a straightforward process in implementing.”
She noted that Oklahoma currently is in the middle of implementing Medicaid expansion as well, and is the only other state that did so through an amendment to the state’s constitution.
Because expansion was not implemented prior to the American Rescue Act, Missouri should receive about $2.8 billion in federal funding.
The expansion would cover working-age adults who earn up to 138 percent of the federal poverty guideline, or $17,774 a year for a single person.
That is 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 time at $17.58 an hour or two people working a combined 68 hours a week at minimum wage.
Without expansion, Missouri has one of the most restrictive Medicaid eligibility levels for parents and childless adults in the nation, according to the Missouri Budget Project. As it stands, the program provides coverage for low-wage parents earning no more than $388 per month for a family of three, the lowest level allowed under federal law and the third-lowest eligibility level in the nation.
“I feel like my hands are tied and I cringe when I see patients incur negative and long-term consequences from medical conditions that could have been prevented,” Dr. Heidi Miller said about her uninsured patients.
“… I know that we need to be stewards of our limited resources and so when I see our system is designed to pick up the tab for a very costly hospitalization, but not for the very affordable preventable steps, I feel really sad for our patients and this state.”
Miller has practiced internal medicine as a primary care doctor since 2013 at Family Care Health Centers, one of the Federally Qualified Health Centers in St. Louis. She also serves as Regional Health Commission medical director.
She said most of her patients are employed and fall in the coverage gap — meaning their income is too low to be eligible for premium tax credits, but too high to qualify for Medicaid coverage.
“Patients are hyper aware of their ability to access care or not, and if they don’t access care, they neglect their health and when you neglect your health you can have catastrophic outcomes,” she said.