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Medicaid Expansion Fans And Foes Make Familiar Arguments In Missouri’s High-Stakes Case

medicaid expansion ballot question
Nat Thomas
St. Louis Public Radio

The arguments for and against Missouri Medicaid expansion that are about to be heard in Cole County Circuit Court are not surprising.

Three plaintiffs who would qualify for Medicaid based on passage of a 2020 constitutional amendment say that Missouri has no choice but to let them sign up for the health care program. Missouri Attorney General Eric Schmitt’s office counters that since the legislature didn’t appropriate money, the amendment is basically inoperative.

“We chose to prioritize the vulnerable in society that do rely on Medicaid benefits,” said House Budget Chairman Cody Smith, R-Carthage, last month. “Those folks that aren’t able to work, who are unable to provide for themselves, or obtain health benefits under their own volition — as opposed to those who are working age and able-bodied.”

These contentions are basically what lawmakers for and against Medicaid expansion made throughout the 2021 legislative session. At stake is whether an additional 275,000 Missourians gain access to Medicaid.

“It’s a complete political game,” said House Minority Leader John Rizzo, D-Independence, last month. “And it’s a game that they’re playing with people’s lives.”

Representative Cody Smith, R-Carthage, speaks at a press conference after the House finishes the final day of the session at the Missouri State Capitol Building on Friday, May 14, 2021, in Jefferson City. Smith was a critical figure in the decision not to fund Medicaid expansion.
Daniel Shular
Special to St. Louis Public Radio
Rep. Cody Smith, R-Carthage, speaks at a press conference after the House finished the final day of the session at the Missouri State Capitol on May 14. Smith was a critical figure in the decision not to fund Medicaid expansion.

The case in court

The case pending before a Cole County judge involves three women who currently earn too much money to qualify for Medicaid if the eligibility criteria isn’t expanded. The 2020 constitutional amendment allows people who make up to 138% of the federal poverty level, or about $17,800 for a single person.

The plaintiffs’ attorneys argue that the legislature’s decision not to appropriate money for expansion doesn’t remove responsibility for the state to allow people in the expansion population to sign up for coverage by July 1. The lawsuit also states that the state is violating another part of the constitutional amendment requiring agencies to maximize federal reimbursement for Medicaid.

“The agencies claim that they lack the authority to implement Medicaid expansion because the General Assembly did not include a specific appropriations line item funding services for the newly eligible population. This position has no merit,” the lawsuit states. “The [Department of Social Services’] appropriations bill does not limit any [Medicaid] funding for coverage of particular categories of eligible individuals. Nothing in the DSS appropriations bill prevents the agencies from using appropriated funds to cover individuals whose eligibility arises under the Constitution.”

John Sauer, the attorney handling the Medicaid expansion case for Schmitt’s office, counters that “the constitutional amendment purportedly authorizing Medicaid Expansion could not and did not mandate an appropriation — rather, the General Assembly retained authority to appropriate, or not appropriate, funds for Medicaid expansion.”

“Because the General Assembly did not do so,” Sauer wrote, “defendants lack authority to implement Medicaid expansion and they lack appropriations authority to disburse taxpayer funds for that purpose.”

Sauer also wrote that the availability of “additional federal funds to offset some of the costs of Medicaid expansion … does not make up for the lack of appropriations authority under state law to expend any funds, whether state or federal, for the purpose of implementing Medicaid expansion.”

Bound for the Supreme Court

The case over Medicaid expansion is slated to begin later this month before Cole County Judge Jon Beetem. But whatever happens in that courtroom is almost certain to be appealed to the Missouri Supreme Court.

Lowell Pearson, one of the plaintiffs’ attorneys, told KBIA’s Health and Wealth Desk that he expects a quick decision.

“The lawyers involved on our side and the lawyers for the Attorney General’s Office who are representing the defendants are all very experienced in expedited litigation,” Pearson said. “All of us have practices that involve ballot measures.”

If the court rules in favor of the plaintiffs, it’s likely that the state’s Medicaid program would run out of money without a supplemental appropriations bill to pay for expansion. And if the legislature refused to do that, then health care providers could stop seeing reimbursements for Medicaid — which some observers believe would be such a bad scenario that lawmakers would have no choice but to appropriate funds.

Asked about that scenario, House Majority Leader Dean Plocher said Tuesday on Politically Speaking that “interpreting how the courts would view this — again I have to believe in the separation of powers.”

“I also believe that it’s up to the legislative process to allocate funding,” said Plocher, R-Des Peres. “And I believe that allocating funding is part of the legislative process. That’s why the budget begins in the state House and then goes to the Senate. It’s up to the legislative body to allocate money and spend the money — and as a whole we have to be good fiscal stewards.”

Pearson told KBIA that he expects the separation of powers argument to be used throughout the case.

“I don’t think it’s true here, where we have a constitutional right to this health care,” he said. “So ultimately I suppose the court will have to measure those two constitutional principles and decide which one is the more important.”

Follow Jason on Twitter: @jrosenbaum

Jason is the politics correspondent for St. Louis Public Radio.

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