Autumn Stultz helped fundamentally change Missouri.
That may seem like hyperbole, but the single mother from Springfield was one of three plaintiffs in a landmark legal case in which the Missouri Supreme Court ruled that a 2020 ballot item expanding Medicaid was valid — and that the state has to sign up thousands of Missourians who constitute a segment of the working poor.
And while Stultz said that enrolling in Medicaid will help her personally, she’s conscious about how victory in court affected so many people and institutions.
“I was overjoyed for all of the Missourians who can finally receive what we’ve all been asking for,” Stultz said.
Once it's implemented, Medicaid expansion will have immense consequences for people, health care providers and legislative politics. It also marks a climatic point in a political debate that’s stretched on for more than 15 years.
As the dust over the judicial decision clears, here’s what happens next with Medicaid expansion:
Medicaid expansion opens health care program up to nearly 275,000 people
When Kansas City resident Nina Canaleo got word that the court ruled in favor of Medicaid expansion proponents, she thought she was dreaming.
“I’m really ecstatic,” Canaleo said during a telephone interview the day the court decision was handed down. “It’s one thing I won’t have to worry about. And it's an important thing. It could be me walking or not. And that’s huge in somebody’s life, considering that I work and I can’t afford to get my own health care.”
Canaleo, a maintenance worker who has multiple sclerosis, was outraged earlier this year when the legislature refused to provide money for expansion — and Gov. Mike Parson pulled plans to implement it. Now, she’s preparing to sign up for a program that could help her pay for medication that will substantially improve her life.
“They throw us crumbs once in a while. But this is a big crumb,” Canaleo said. “It’s a huge, meal crumb that’s going to last.”
The court’s decision means that the state must provide services to people who make up to 138% of the federal poverty level. That’s about $17,800 a year for an individual or about $36,000 for a family of four. Before the ruling, Missouri limited access to Medicaid to people with disabilities, children and truly destitute families. A single mom with one kid had to make less than $3,000 a year to qualify.
“It is a gamechanger, because having health coverage supports work,” said Joel Ferber of Legal Services of Eastern Missouri, who helped with the Medicaid expansion case. “The reality is a lot of these low-wage jobs don’t provide health insurance. This is going to be a way for these low-income folks who want to work to get coverage.”
Medicaid expansion could change the way people access health care providers
Missouri’s hospitals were a major force behind getting the Medicaid expansion measure on the ballot. And while expansion could cut down on the amount of uncompensated care, Dave Dillon of the Missouri Hospital Association said it won’t completely eliminate it.
“The big win here is not as much for us as it is for people who are delaying care — or potentially dying because they think they can’t afford it,” Dillon said. “Hospitals in Missouri did $1.5 billion of uncompensated care. Medicaid expansion will reduce that number. But that number will not go away.”
Rather, Dillon said the more impactful consequence of Medicaid expansion could be that low-income Missourians seek out outpatient and primary care more — and don’t put off medical appointments so much that they end up in the emergency room.
“This is going to allow us to put a lot of people who otherwise would have gone through emergency departments sicker than they have to go through outpatient care or primary-driven care to improve their health,” Dillon said.
Case in point: Stultz said once that she’s signed up for Medicaid, she’ll have a much easier time getting inhalers and anxiety medication. And she said she’ll be more proactive about going to the doctor on routine visits.
“So with the enrollment and getting approved and being able to go in and get initial blood work done and all these other tests done — to have that preventive care again would be great,” Stultz said.
Program opens up for childless individuals, and help parents
Because of the passage of the Medicaid expansion amendment, Missouri will offer the program to childless adults — which wasn’t the case before the Supreme Court decision.
And while Missouri historically has been generous when it comes to accepting kids on Medicaid, most often their parents haven’t been eligible. That will change with expansion. Cynthia Rogers, a child psychiatrist and assistant professor of psychiatry at Washington University, said that could bring about major benefits to families.
“It’s extremely stressful for the parent knowing that they’re ill, but they’re not taking care of themselves,” Rogers said. “It really impacts their ability to appropriately parent their child the way that they’d want to. And it also impacts the financial stability of the family.”
In addition to helping improve health outcomes in rural Missouri, Rogers said the Medicaid expansion could reduce unequal levels of care and improve health for Black people.
“We know other studies show that Medicaid expansion decreased disparities and infant mortality and preterm birth for Black infants compared to states that didn't expand Medicaid,” Rogers said. “So that's definitely one of the things that many of us are very hopeful about that Medicaid expansion.”
Courts and legislature still have to fund Medicaid expansion
The legal pathway for Medicaid expansion to happen is not technically complete yet.
The Missouri Supreme Court sent the case back to Cole County Judge Jon Beetem, who still needs to enter an order preventing the state from denying people in the expansion population Medicaid coverage.
That should happen in the coming days. And Chuck Hatfield, one of the attorneys in the case, said he expects the state to be ready to start accepting newly eligible people into the program soon.
“They do have some things on there they need to do to make sure that when the switch goes on, they're actually able to process everybody and communicate to the provider community that these folks are eligible,” Hatfield said. “I anticipate it's a matter of a couple of days to get that system up and running. But we'll need to hear from the state on that. If they think it's going to take a few more days, they can explain that to the judge. I doubt we'll have any objection to reasonable time to get implementation going.”
Parson spokeswoman Kelli Jones said in a statement last week that “after today’s court decision, the executive branch still lacks the necessary budget authority to implement MO HealthNet coverage to the expanded population.” Hatfield said that may be a reference to how the legislature needs to provide Parson authority to spend the federal match for Medicaid expansion.
“They'll get the cash,” said Hatfield, noting that the federal government should provide matching funds for expansion when a plan is submitted. “But the executive branch needs appropriation authority to spend it. And I assume that's what they meant.”
“They've got the money to enroll people tomorrow,” he continued. “That's what the Supreme Court said. And I think as a matter of math, they could provide these services for a month or two months or whatever that number is. But I assume they mean they want more authority to pull in the federal money.”
Court decision shifts Medicaid expansion from aspirational to essential
The Supreme Court decision did not force the legislature to provide more funds to accommodate expansion. But doing nothing would mean that the program would run out of money and that health care providers wouldn’t get reimbursed for care. That would likely spark an unprecedented crisis throughout the state.
Hatfield compared the current state of affairs to a recent standoff over a tax on health care providers that helps pay for Medicaid. He pointed out that Parson was preparing for steep budget cuts if the legislature didn’t act.
“This is no different than any other new law that gets passed. It gets passed, and then there's discussion about how you're going to fund it,” Hatfield said. “The legislature can fund it, they could not fund it, they could fund it somewhere in the middle.”
Senate Minority Leader John Rizzo, D-Independence, said now that the pool of Medicaid recipients includes people in the expansion population, the pressure to make sure the program is fully funded will be immense.
“The ball is squarely in their court on how far they want to take it,” said Rizzo, referring to GOP legislators. “The highest court in the land says the population needs to be expanded, I’m not quite sure where you can go from there.”
Focus of lawmakers may move onto long-term costs, which may not be that high
Under the Affordable Care Act, the federal government would pay for 90% of the cost of Medicaid expansion — leaving the state with the responsibility of paying for the other 10%. Republicans have consistently opposed the idea because they contended it would be a long-term drag on the state’s finances.
That shouldn’t be an issue, at least in the short term. That’s because Missouri has a hefty surplus — and is poised to get around $1 billion from the federal American Rescue Plan that could pay for the state match for years. Ferber also said it’s not necessarily a sure thing that Medicaid expansion will perpetually cost the state money.
“The way it works is that federal money comes in at a higher match rate that replaces state-funded services or services that were funded at a lower match rate before,” Ferber said. “So the states end up in better shape because of it. And obviously, the American Rescue Plan provides over a billion dollars over the next five years. I don’t see budgetary issues as a result of this constitutional category being implemented.”
If that prediction ends up being wrong and Medicaid expansion still requires a significant allocation of state money, the legislature does have time to figure out a permanent funding source.
But Rep. Tony Lovasco, R-St. Charles County, said his colleagues are still absorbing the ruling’s impact before deciding their next move.
“I don't think all that much has changed by this ruling,” Lovasco said. “I think, ultimately, when we voted not to appropriate the money, I think we did so with the understanding that the constitutional amendment did pass and there are some amount of obligations that come with that. And the particulars can be worked out. But ultimately this is about whether or not the legislature has the power of the purse. And I think it's pretty clear that the Supreme Court says we do.”
Implementation will end nearly 15-year struggle to expand Medicaid
For passive observers of Missouri politics, Thursday’s ruling was largely about whether a 2020 ballot item that the people voted for would actually go into effect.
But people like Bob Pund know that the struggle to expand Medicaid has gone back much further than August 2020.
Pund is a Columbia resident who spent much of the 2000s decrying steep cuts to Medicaid that were enacted in 2005. Despite the election of Democratic Gov. Jay Nixon and the implementation of the Affordable Care Act, efforts to reverse those cuts continuously faltered. And the prospect of expansion seemed dim until the arrival of the 2020 ballot item.
“Really, Missouri was cutting off its nose to spite its face, without any rational reasons,” Pund said. “Not for budget reasons. It was a philosophical thing that hurt Missourians.”
Pund said the expansion passed because Missourians looked at it differently. “I think it’s a less looking at policy and it’s more looking it as a social thing,” he said.
Pund is a quadropalegic and receives Medicaid benefits. One thing he noted was how many of the people who help take care of him can now qualify for the program, something he called a “virtuous circle.”
“Of course the main outcome is better health outcomes and helping poor people more,” Pund said. “That’s a good thing in and of itself. But it’s going to help the Missouri economy as a whole too. I think as far as this goes, I think the case is closed. Once this starts, you’re not going to be able to take it away. Because people will like it and see the need of it.”
Follow Jason on Twitter: @jrosenbaum
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