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Fate Of Medicaid Expansion Now In Hands Of Missouri Supreme Court

The Missouri Supreme Court has ruled that a 2020 ballot initiative that expanded Medicaid in the state did not violate the law.
Nat Thomas
St. Louis Public Radio
The Missouri Supreme Court has ruled that a 2020 ballot initiative that expanded Medicaid in the state did not violate the law.

Missouri Supreme Court judges will decide whether roughly 275,000 people will gain access to the health care program.

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 whether 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 opinion striking down the 2020 constitutional amendment that expanded Medicaid to individuals making roughly $17,800. Cole County 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 since 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 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.”

For the most part, 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 expansion 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 a climatic moment in a nearly decade-a-half push to expand Medicaid.

Back 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 hospital 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 the endeavor.

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 House 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 they all have serious health conditions in which 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 the case has been moved through the process fairly quickly.

Follow Jason on Twitter: @jrosenbaum
Copyright 2021 St. Louis Public Radio. To see more, visit St. Louis Public Radio.

Since entering the world of professional journalism in 2006, Jason Rosenbaum dove head first into the world of politics, policy and even rock and roll music. A graduate of the University of Missouri School of Journalism, Rosenbaum spent more than four years in the Missouri State Capitol writing for the Columbia Daily Tribune, Missouri Lawyers Media and the St. Louis Beacon. Since moving to St. Louis in 2010, Rosenbaum's work appeared in Missouri Lawyers Media, the St. Louis Business Journal and the Riverfront Times' music section. He also served on staff at the St. Louis Beacon as a politics reporter. Rosenbaum lives in Richmond Heights with with his wife Lauren and their two sons.
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