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Government, Politics & Issues

Fate Of Missouri Medicaid Expansion Now In Hands Of State Supreme Court

medicaid expansion ballot question
Nat Thomas | St. Louis Public Radio
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Both sides of a legal battle over voter-approved Medicaid expansion made their cases in front of the Missouri Supreme Court on Tuesday.

At stake is whether roughly 275,000 people gain access to the health care program — or expansion remains out of reach in Missouri for the foreseeable future.

The state’s high court heard an appeal of a Cole County judge’s decision striking down the 2020 constitutional amendment that expanded Medicaid to individuals making up to roughly $17,800. Circuit Judge Jon Beetem ruled that the amendment was unconstitutional, because it bars initiatives requiring “the appropriation of revenues not created by the initiative.”

One of the attorneys for three women seeking to gain access to Medicaid, Chuck Hatfield, said Beetem was incorrect in his ruling that the Medicaid expansion amendment was unconstitutional. He also disputed Attorney General Eric Schmitt’s contention that Medicaid expansion doesn’t have to happen because the legislature didn’t appropriate money, noting that budget writers did not provide distinctions for eligible population groups.

“Here, we ask this court to remind the executive branch that the people, by a vote to amend our constitution, have required the executive branch to enroll our clients in the [Medicaid] program,” Hatfield said during oral arguments. “There doesn’t seem to be any dispute that the constitution says they shall be enrolled. There’s no dispute that they’re qualified to be enrolled.”

John Sauer, who serves as the state solicitor general and is a staffer in Schmitt’s office, rejected Hatfield’s argument that the legislature’s decision to fund the state’s Medicaid program also in turn funded access for the state’s working poor.

“Their interpretation only makes sense if you don’t understand basic features and basic details about Medicaid that are set forth in federal statutes and regulations that this court can take judicial notice of,” Sauer said during oral arguments. “And that's a textbook example of poor interpretation.”

The Supreme Court judges asked few questions. But Judge W. Brent Powell did ask Sauer how the court can “look back at an election, on an amendment that is passed and decide that was invalidly passed?”

“And if so, if we can do that, how long can we continue to do that?” Powell asked. “Can we go back and look at medical marijuana and decide that was passed invalidly?”

Sauer replied that his office’s argument is that the court added that prior case law showed that litigation over whether an initiative should be preserved or struck down should come after it’s passed — as opposed to when it’s put up for a statewide vote.

The Medicaid amendment “can be interpreted to establish eligibility, which is a very significant development in the law, and mandate eligibility, but without requiring the legislature to fund it — which is set forth in multiple provisions over appropriations,” Sauer said.

After oral arguments, Hatfield said that courts typically shy away from decisions that amount to “absurd results.”

“It is absurd to say that the people voted to expand Medicaid and to include our clients in the Medicaid program, and then by virtue of some legislative maneuvering an appropriations bill they could be excluded,” Hatfield told reporters after oral arguments concluded. “What that’s arguing to do is to overturn an election. And that’s pretty serious business that I don’t think this court is going to engage in.”

High-stakes battle

In many respects, Tuesday’s oral arguments serve as a climactic moment in a nearly decade-and-a-half push to expand Medicaid.

In 2005, then-Gov. Matt Blunt signed legislation sharply cutting Medicaid eligibility. Right now, a single mother who is not disabled must make less than $3,000 to qualify for the program. Someone who has no children and is not disabled can’t qualify at all for Medicaid.

“We have among the lowest in the entire country, which is one of the reasons it’s an issue,” said Joel Ferber of Legal Services of Eastern Missouri.

Efforts by Missouri Democrats, including then-Gov. Jay Nixon, to reverse that decision were unsuccessful. So in 2020, Missouri’s hospitals helped bankroll a successful ballot initiative to expand the program. But Gov. Mike Parson pulled back on the expansion after the legislature refused to appropriate money for it.

If the court sides with the three women seeking to get on Medicaid, what will likely happen is that Medicaid will run out of money. The legislature will have little choice but to pursue a supplemental appropriations bill to prevent health care providers from not being reimbursed.

But if the state rules that the Medicaid expansion amendment is effectively inactive without the legislature appropriating money, then it’s unlikely that Missouri will adopt expansion any time soon — especially since the state’s GOP majorities in the legislature are unlikely to shift in a meaningful way.

Thus far, a number of groups have submitted amicus briefs on both sides. House Republicans called for the court to sustain Beetem’s ruling. Many of them, including Majority Leader Dean Plocher, R-Des Peres, have said expansion is a bad long-term fiscal move for the state.

“It's up to the legislative body to allocate funding and spend the money,” Plocher said in a recent edition of Politically Speaking. “And I think as a whole, we have to be good fiscal stewards of how we're doing that.”

But regional groups, health care providers and House Democrats have argued that the court should effectively preserve the Medicaid expansion amendment. And proponents have noted that Missouri could get over a billion dollars from the federal stimulus bill if Medicaid expansion is implemented, which would likely pay for the state portion of the program for years.

Ferber also said that the decision has immense implications for the three women who are serving as plaintiffs. He noted that they all have serious health conditions, and that Medicaid could pay for treatment.

“They’re all struggling,” said Ferber, who noted that the three plaintiffs were not in Jefferson City on Tuesday. “And so they’re all hoping and counting on this Medicaid expansion to go through to meet the needs that they have.”

It’s unclear when the court will rule in the Medicaid expansion case, though Hatfield pointed out that it has been moved through the process fairly quickly.

Follow Jason on Twitter: @jrosenbaum

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