Missouri Supreme Court Unanimously Upholds Medicaid Expansion

Missouri Supreme Court Unanimously Upholds Medicaid Expansion

On Thursday, July 22, The Missouri Supreme Court unanimously upheld the will of the Missouri voters in expanding Medicaid to people earning up to 133% of the federal poverty level (FPL).

AARP Missouri has been working on the issue of Medicaid Expansion since 2005, when the Missouri General Assembly and then Governor Matt Blunt cut eligibility to the Medicaid Program from 100% of FPL to 85% for older and disabled Missourians and under 20% for custodial parents, leaving over 100,000 low-income Missourians without health insurance.

When the Affordable Care Act passed in Congress in 2009, it required that all States raise their eligibility levels to ensure that health coverage would continue until low-income Americans could reach the subsidies that would be provided in the health care marketplace.

The United States Supreme Court then ruled that Congress could not make the expansion of Medicaid mandatory, leading to over a decade of work across the country to expand state-by-state.

Missouri’s General Assembly considered several measures over the years for expansion. Many of the measures proposed a “Missouri Plan” that would include cost control measures and work requirements for enrollees. When the last of these measures failed to even pass one chamber of the General Assembly, several organizations began looking into taking the issue to the ballot.

 In 2019, AARP Missouri was approached by the Missouri Hospital Association and the Missouri Chamber of Commerce – two organizations opposing AARP on issues in the recent past – to join the coalition considering a ballot initiative for Medicaid Expansion. While the coalition agreed that AARP could make a much bigger impact outside of the “official campaign,” AARP became the organization tasked with outreach to the largest group of voters – the 50+.

Ballot language was finalized and signatures were gathered early which proved to be essential to the campaign after the COVID-19 Pandemic hit – essentially halting any signature gathering or door-to-door campaigning.

When the signatures were submitted, there were more than enough for certification and Secretary of State Ashcroft moved at historic speed to get the issue onto the 2020 August Primary Ballot rather than the General Election in November. This move cut months out of the campaign that was already going to be different than any other due to the Pandemic. AARP Missouri became the most essential partner since historically, voters over the age of 50 had been 70% of the primary election electorate.

In August, many political prognosticators were surprised to see that the ballot initiative passed by more than 6 points by a more conservative electorate in an already conservative State. Proponents and opponents alike expected that the issue would eventually go to court, but AARP Missouri hoped that we would be able to convince the Governor and General Assembly to support the will of the voters and begin enrolling Missourians in the program.

When the General Assembly failed to pass a specific line item in the State Budget, proposed by Governor Parson, that would expand Medicaid, the Governor pulled the proposed State Plan Amendment, laying the groundwork for the issue to move quickly to court. The Attorney General agreed to an expedited schedule to get the issue resolved.

Cole County Circuit Judge Jon Beetem ruled that the will of the voters should be followed, but that the amendment to the State Constitution, itself, was unconstitutional since another article in the Missouri Constitution includes a prohibition on ballot initiatives that require an appropriation but don’t have a funding source included. Since this decision directly contradicted the Missouri Supreme Court’s decision to allow the amendment on the ballot in the first place, it opened the door to skipping the district courts and moving directly to the Missouri Supreme Court.

Even in the Supreme Court, neither the State nor the Plaintiffs argued that the lower court decision had been decided correctly. The Attorney General’s Office argued that the General Assembly has the ultimate decision on appropriations, even in the case of a constitutional requirement. The Plaintiffs argued that the will of the Missouri voters should be the highest law, but also that if the General Assembly appropriated any funds for the Medicaid Program, which does not section out any other eligibility categories into individual line items, the State must expend the funds required for expansion.

While we expected a positive hearing from the Court, and hoped for a positive ruling, no one expected a unanimous decision – including Judge Ransom, just appointed by Governor Parson a few weeks ago.

Many in the General Assembly are already talking about ways to cause more problems for Medicaid Expansion, but it is thought that there will be little that can be done to prevent enrollment from beginning next month. Of more concern is the possibility that the General Assembly will move to limit the ability for voters to amend the State Constitution or politicize the ways that Judges are selected.

The state is currently putting this new enrollment plan together, and we will continue to update you with more information.