On Aug. 4, by a vote of 53.25%, Missouri voters approved Constitutional Amendment 2 to expand Medicaid eligibility as of July 1, 2021. The amendment was placed on the ballot due to an initiative petition, with citizens bypassing the state legislature.
The action builds on the federal Affordable Care Act of 2014, which previously had prompted 37 other states and the District of Columbia to expand their Medicaid programs.
The next step for Medicaid expansion in Missouri is the General Assembly. Because this is a constitutional amendment, the legislature does not have the ability to make changes to its provisions. The General Assembly must implement the amendment’s wording as approved by the voters, regardless of any perceived imperfections or difficulties.
Under federal law, Missouri will be reimbursed for 90% of the cost for newly eligible Medicaid recipients. The remaining 10% must be funded by the state from the initial year through all subsequent years. That 10% was the basis for much of the opposition to Amendment 2.
Most opposition was from Republicans and rural voters. Preceding the vote, St. Charles area Sen. Bob Onder, (R-District 2) voiced his opposition to Amendment 2 by publicly stating: “The money needed to expand Medicaid is going to come from somewhere. It either has to come from education, from roads or from massive tax increases. … I do think that Missourians, particularly in these challenging economic times, will realize that a massive expansion of the Medicaid program isn’t something that we can afford.”
After the election, Onder, who is also a physician, took to Twitter to reiterate his concern: “@MissouriGOP and @GovParsonMO always said Missouri could not afford #Obamacare#MedicaidExpansion, even before #Covid recession.”
The General Assembly and governor are bound by the 1980 Hancock Amendment requiring a balanced state budget each year. That means funds added to the budget in 2021 and beyond to cover the state’s 10% portion of expanded Medicaid costs must be offset by some combination of revenue [tax] increases and spending decreases in other areas. Intense legislative battles can be expected between now and July 2021 to determine from where the funds for expanded Medicaid will come.
Due to declining state revenue, Gov. Mike Parson cut $449 million from the 2021 budget, effective this past July 1, with the largest cuts in education. At that time, Parson indicated that COVID-19 was to blame.
“COVID-19 is unlike anything we have ever experienced before,” Parson said on June 30. “As difficult as these decisions are, we are experiencing an unprecedented economic downturn, which means we are having to make unprecedented adjustments in our budget.”
The longer-term statewide economic effect of the COVID-19 pandemic remains to be measured and forecast but will no doubt impact Medicaid expansion funding. Prior to and after the Aug. 4 vote, Parson questioned where the funding for expanded Medicaid will come from in 2021 and beyond.
Looming in the near future are the statewide elections on Nov. 3, 2020, for governor, lieutenant governor, state senators, state legislators, attorney general, treasurer and state judges, all of which could in some way affect the implementation of expanded Medicaid and especially how it is funded. The next scheduled legislative session begins at noon on Wednesday, Jan. 6, 2021.
Support for Amendment 2 mostly came from urban areas in and around St. Louis, Kansas City, Springfield and Columbia. A coalition of more than 250 groups supported the amendment, including the Missouri Chamber of Commerce, Missouri Hospital Association, NAACP, AFL-CIO and AARP.
Currently, Medicaid covers nearly all adults with income levels up to 138% of the federal poverty level, $17,236 per year for an individual and $28,676 for a family of three. But there are gaps in coverage for low-income people who work one or two jobs, make less than $18,000 as an individual or up to $36,000 as a family of four, and do not have health care coverage through their employer. The goal of the expansion is to close that gap.
Washington University in St. Louis supported Amendment 2. On its website, the university states that Medicaid expansion will provide healthcare to 230,000 Missourians and deliver $1 billion of Missourians’ tax dollars back to the state from Washington in terms by way of the 90% federal reimbursement.
The university’s webpage also states that economic output in Missouri will increase by $2.5 billion as a result of Amendment 2’s passage and 16,000 new jobs will be created. The Missouri Chamber of Commerce estimates those same numbers.
According to the Kaiser Family Foundation website, under the expansion authorized by Amendment 2, about 205,000 uninsured non-elderly Missouri adults now will be eligible for Medicaid. Seventy-six percent of those are childless adults, a group historically excluded from eligibility. Nearly 8 in 10 are in a family with at least one worker. More than 3 in 4 are adults living in poverty. More than 7 in 10 are white, non-Hispanic. More than 3 in 10 are middle-aged and 17% are near-elderly and more likely to have substantial health needs. The foundation clarified that 98,000 uninsured, or nearly half, are women.
According to Washington University, 36,000 more African American Missourians will have access to health care as a result of Amendment 2.
The Kaiser Family Foundation is an independent national organization that uses policy analysis, polling and survey research to report on national health issues.