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Missouri and the ACA’s Medicaid expansion

Supreme Court rules that voter-approved Medicaid expansion must be implemented; 275,000 expected to gain coverage

Key takeaways

Missouri Supreme Court rules that Medicaid expansion must be implemented

Although the federal government began providing funding to expand Medicaid in 2014, Missouri is one of 13 states that had continued to reject Medicaid expansion. But that will soon change as a result of a unanimous Missouri Supreme Court ruling that was issued in July 2021.

Voters in Missouri approved a Medicaid expansion ballot measure in August 2020 by a margin of about 53 to 47. It called for the state to submit a Medicaid expansion state plan amendment to the federal government by March 2021, and for Medicaid expansion to take effect by July 1, 2021.

In keeping with the timeline called for in the ballot measure, the Missouri Department of Social Services (DSS) submitted a proposed Medicaid expansion plan to HHS in February 2021, calling for Medicaid expansion to take effect July 1.

But when state lawmakers passed the 2022 fiscal year budget, they refused to include funding for the state’s portion of the cost of Medicaid expansion. Lawmakers did allocate normal funding for Medicaid (MO HealthNet), but the DSS indicated that it would not change the eligibility criteria for Medicaid coverage, since lawmakers had not expressly allocated funding for that purpose. And the state withdrew the Medicaid expansion state plan amendment that it had submitted to HHS earlier in the year.

A lawsuit ensued, with plaintiffs who would be eligible for Medicaid expansion suing DSS. DSS argued that the ballot initiative itself was unconstitutional, since the state constitution clarifies that ballot measures cannot be used to appropriate state funds. In late June 2021, a circuit court judge ruled that Missouri’s Medicaid expansion ballot measure was unconstitutional because it didn’t include a funding mechanism (it had left that up to lawmakers, as has been the case in other states where Medicaid has been expanded via ballot measure). So Medicaid expansion did not take effect in Missouri on July 1.

The case was appealed, and the Missouri Supreme Court heard oral arguments on July 13, 2021. The following week, the Supreme Court vacated the lower court’s ruling, and noted that the Medicaid expansion eligibility criteria outlined in Missouri Article IV, Section 36(c) are “now in effect.” That’s the section of the Missouri code that contains the Medicaid expansion language stipulated in the voter-approved ballot measure, including the fact that the new eligibility rules are effective July 1, 2021.

This means that MO HealthNet eligibility must be expanded to include adults under age 65 with household incomes up to 138% of the poverty level. In 2021, that amounts to about $17,774 for a single individual, and $36,570 for a household of four (children are already eligible for Medicaid at higher income levels). Once implemented, this is expected to result in 275,000 Missouri residents becoming eligible for MO HealthNet.

The details still need to be sorted out, as the state plan amendment has been withdrawn and will need to be resubmitted to HHS. Lawmakers will also have to sort out any remaining funding issues, since the amount currently allocated for MO HealthNet may be insufficient with the newly eligible population added to the state’s Medicaid rolls.

Although Medicaid expansion was supposed to take effect in Missouri on July 1, the state Supreme Court’s ruling came more than three weeks later, and the logistics still need to be sorted out between DSS and the federal government. There is some precedent for this, however, with the way Medicaid expansion was implemented in Maine in 2019 (it was supposed to take effect in July 2018, but was delayed several months due to the governor’s opposition; once it was implemented, coverage was backdated to when people had applied, with retroactive effective dates as far back as July 2018).

Until Medicaid expansion actually takes effect in the state, non-disabled adults without children are not eligible for Medicaid in Missouri (MO HealthNet) regardless of how low their income is, and parents with dependent children are only eligible with incomes that don’t exceed 22% of the poverty level. Only Texas and Alabama have lower Medicaid eligibility caps, at 18%. For now, 127,000 people remain in the coverage gap in Missouri — unable to qualify for Medicaid because the state still has not expanded eligibility for Medicaid coverage, and unable to qualify for premium subsidies in the exchange/marketplace because they earn less than the poverty level.

Missouri is the sixth state to expand Medicaid via ballot measure

In the last few years, voters in Maine, Idaho, Nebraska, Utah, and Oklahoma have approved similar ballot measures to expand Medicaid. Missouri will be the sixth state to expand Medicaid in this manner.

It’s also worth noting that while voters in Utah, Idaho, and Nebraska all approved Medicaid expansion ballot initiatives in 2018, all three states subsequently sought federal approval for Medicaid work requirements (Utah’s took effect in January 2020, but was suspended in April 2020 amid the COVID-19 pandemic), and have imposed various other restrictions and requirements, as opposed to simply expanding Medicaid as called for in their voter-approved ballot initiatives.

But the amendment that voters passed in Missouri prohibits the state from imposing additional eligibility requirements (other than the ACA’s income and immigration requirements) on the expansion population that aren’t imposed on the rest of the state’s Medicaid-eligible population. The Biden administration has also notified states that work requirements will no longer be approved, so that would be a non-starter at this point.

Missouri has missed out on billions in federal funding

In states that expand Medicaid, the federal government paid the full cost of expansion through 2016. Starting in 2017, the states gradually started to pay a share of the expansion cost, and states now pay 10% of the cost (the 90/10 split will remain in place going forward). Because of the generous federal funding for Medicaid expansion, states that reject it are missing out on billions of federal dollars that would otherwise be available to provide healthcare in the state.

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From 2013 through 2022, Missouri was projected to give up $17.8 billion in federal funding by not expanding Medicaid.

Hospitals in Missouri that treat uninsured patients have been especially hard-hit, as their federal disproportionate share hospital funding has started to be phased out (it was supposed to be replaced by Medicaid funding) and the uninsured rate has remained higher than it would have been with Medicaid expansion in place. As a result of Missouri’s decision to opt out of Medicaid expansion, hospitals in the state were projected to lose $6.8 billion between 2013 and 2022.

Movement toward Medicaid expansion in Missouri

SB371, introduced in Missouri’s legislature in 2018, called for putting Medicaid expansion on the November 2018 ballot and letting voters decide, but the bill did not advance. A citizen-led effort to get Medicaid expansion on the ballot in Missouri was considered a non-starter in 2018, as it didn’t have the backing of any major groups at that point.

But in 2019, things were different. Healthcare for Missouri picked up the push for a ballot initiative, and received support and funding from The Fairness Project, which helped with the expansion ballot initiatives in other states in recent years.

The ballot initiative was submitted to the state in June 2019, and was approved for the signature-gathering process to begin. Advocates spent the summer determining the feasibility of Medicaid expansion by ballot initiative in Missouri, and announced in September 2019 that they would commit to gathering the 172,000 signatures necessary for the measure to appear on the ballot.

Dozens of petition-signing events took place in communities around the state in the fall of 2019 and early 2020. Although the COVID-19 pandemic put a halt to in-person signature gathering as of March 2020, Healthcare for Missouri announced at that point that they would still be able to submit the necessary number of signatures by the early May deadline, “thanks to a strong and early start to voter signature collections” in 2019.

The signatures had to be submitted by May 3, and Healthcare for Missouri announced on May 1 that nearly 350,000 signatures — almost twice as many as necessary — had been submitted to the Missouri Secretary of State’s office. The Secretary of State certified the signatures a few weeks later, and Governor Mike Parson soon announced that the measure would be on the August 4, 2020 primary ballot, instead of the general election ballot in November.

Parson, who is opposed to Medicaid expansion and the ballot initiative, said that he was placing the measure on the primary ballot in order to give the state more time to implement Medicaid expansion if voters approve it. But supporters of Medicaid expansion, including Parson’s Democratic gubernatorial challenger Nicole Galloway, felt that Parson chose to put the measure on a ballot for a lower turnout election, in hopes that it wouldn’t pass. Oklahoma Medicaid expansion advocates also gathered enough signatures to get an expansion initiative on the ballot in 2020, and Oklahoma’s governor — who is also opposed to Medicaid expansion — also opted to put the ballot initiative on the primary ballot. But voters in both states approved Medicaid expansion, despite the fact that the measures appeared on primary ballots instead of the general election ballots (Oklahoma’s Medicaid expansion took effect July 1, 2021, as scheduled).

Parson made his opposition to Medicaid expansion clear, but he stated that he would “uphold the will of the people” if the Medicaid expansion ballot measure was passed by voters. The Kansas City Star Editorial Board noted in late 2019 that GOP lawmakers in the state could still opt to craft their own version of Medicaid expansion during the 2020 legislative session, incorporating various limitations that could be achieved with an 1115 waiver. But the only Medicaid expansion bills that were introduced in the 2020 session (SB564 and SB603) were introduced by Democrats and did not advance during the session.

Missouri will implement Medicaid expansion by summer 2021
887,433 Number of Missouri residents covered by Medicaid/CHIP as of April 2020
230,000 Number of Missouri residents expected to gain access to Medicaid as a result of expansion
28% Reduction in the uninsured rate from 2013 through 2018

Who is eligible for Medicaid in Missouri?

MO HealthNet coverage is available to low-income children, pregnant women, and very low-income parents of minor children. As soon as the Missouri Supreme Court’s ruling on Medicaid expansion is implemented, coverage will also be available to adults under the age of 65 if their household income doesn’t exceed 138% of the poverty level.

In addition, low-income residents who are aged, blind, or disabled are also eligible for Medicaid, but they’re also subject to fairly strict asset limits in order to qualify for coverage.

How much money can you make to qualify for Medicaid in Missouri?

All Medicaid-eligible populations are subject to income limits (as we’ll discuss in a moment, some populations are also subject to asset limits). In Missouri, Medicaid members must have a household income that doesn’t exceed the following limits:

  • Adults under age 65: Once Medicaid expansion is implemented, these individuals will qualify for Medicaid with household income up to 138% of the poverty level (until then, coverage is only available to parents of minor children, with household income up to 22% of the poverty level).
  • Infants under one are eligible for Medicaid if their household income is up to 196% of poverty. That amounts to about $43,000 in annual income for a household of three in 2021.
  • Children 1 – 18 are eligible if their household income is up to 150% of poverty. For a household of three in 2021, that amounts to just under $33,000 in annual income.
  • Children above the Medicaid income thresholds are eligible for CHIP if their household incomes are up to 300% of poverty.  This is among the more generous limits in the country.
  • Pregnant women are eligible for Medicaid if their household income does not exceed 196% of poverty (and a pregnant woman with one fetus counts as two people for the purpose of counting household size relative to the poverty level).

What is the asset limit for Medicaid in Missouri?

For the groups described above, only an income limit applies. But for Missouri Medicaid applicants whose eligibility is based on their status as aged (65+), blind, or disabled, there are both income and asset limits. This page is a Missouri-specific overview of how this works.

How does Medicaid provide assistance to Medicare beneficiaries in Missouri?

Many Medicare beneficiaries receive help through Medicaid with the cost of Medicare premiums, co-pays, deductibles, and services Medicare doesn’t cover — such as long-term care.

Our guide to financial assistance for Medicare beneficiaries in Missouri explains these benefits, including Medicare Savings Programs, long-term care benefits, Extra Help, and income guidelines for assistance.

How do I enroll in Medicaid in Missouri?

If you are under 65 and don’t have Medicare:

The Missouri Department of Social Services also has information about the managed care plans that are available for MO HealthNet members, and how you can go about selecting one.

If you’re 65 or older or have Medicare, you can use this website to apply for Medicaid.

Missouri Medicaid enrollment numbers

From late 2013 through January 2021, total enrollment in Missouri Medicaid and CHIP grew by about 21%, and stood at 1,023,683 people at the start of 2021. The COVID pandemic played a significant role in driving enrollment higher, in Missouri as well as nationwide. As of April 2021, when the pandemic was just starting to take hold, enrollment in Missouri’s Medicaid program had been just 5% higher than it had been in 2013.

Efforts to expand coverage in Missouri: 2012 – 2016

A University of Missouri School of Medicine study in 2012 concluded that “Medicaid expansion would be highly beneficial to the Missouri economy and its citizens.” And in June 2014, the Missouri Economic Research and Information Center announced that healthcare job growth in Missouri had slowed considerably since 2012, and was falling behind compared with states that had expanded Medicaid.  Healthcare is the state’s largest employment sector.

Former Governor Jay Nixon was a longtime proponent of Medicaid expansion, although the Republican supermajority in the state’s legislature blocked his efforts in 2012 and 2013.

But Senator Ryan Silvey, a Republican from Kansas City, was on board with Medicaid expansion, noting that “it’s going to be damaging to our hospitals if we don’t do something.” Silvey’s Democratic colleagues were also supportive of expansion. The legislature came close to approving a modified version of Medicaid expansion in the spring of 2014, and Silvey noted that some of the lawmakers who opposed it had since retired, meaning there might be a better chance for successful legislation in 2015.

In December 2014, Senator-elect Jill Schupp introduced SB 125, which called for expansion of Medicaid up to 138% of the poverty level, but it did not advance out of committee.

Several other similar bills were introduced during the 2015 session as well, including HB 153, HB 1351, and HB 474.  But Republican leadership in the Missouri legislature vowed to block any attempts to expand Medicaid during the 2015 session, and none of the bills advanced to a full vote. Bob Onder, a new state senator from St. Charles, made fighting Obamacare — including Medicaid expansion — his primary focus during the 2015 session. When the Supreme Court upheld the legality of subsidies in states like Missouri that use Healthcare.gov, Onder stated that the Court’s ruling was essentially liberal justices taking the opportunity to “rewrite” the ACA in order to “save” it.  There was hope — nationwide — that the Court’s ruling on King v. Burwell to uphold subsidies would galvanize the Medicaid expansion movement, since it indicated — at that time — that the ACA was here to stay. But opposition to Medicaid expansion among Missouri’s legislative leadership remained strong.

Unfortunately, the legislature’s refusal to expand Medicaid meant that hospitals had to cut costs, and in June 2015, Mercy Hospital announced 127 job cuts in Springfield.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Apply for Medicaid in Missouri

You can enroll through HealthCare.gov or through MO HealthNet.  You can also enroll by phone at 800-318-2596.

Eligibility: Parents with dependent children are eligible with household incomes up to 18% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 300% of FPL, and pregnant women are eligible with household incomes up to 196% of FPL.

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