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Missouri and the ACA’s Medicaid expansion

New GOP Governor joins legislature in opposing Medicaid expansion

missouri Medicaid guide

Missouri has not expanded Medicaid (MO HealthNet) under the Affordable Care Act (ACA). Non-disabled adults without children are not eligible for Medicaid regardless of how low their income is, and parents with dependent children are only eligible with incomes that don’t exceed 18 percent of the poverty level. Only Texas has a lower Medicaid eligibility cap, at 15 percent.

96,000 in coverage gap

If Missouri had expanded Medicaid, FamiliesUSA estimates that 293,000 people would be newly eligible for coverage.

As the ACA was written, it called for Medicaid expansion in every state for residents with incomes up to 133 percent of poverty (138 percent with the built-in 5 percent income disregard). But in 2012, the Supreme Court ruled that states could not be penalized for opting out of expansion, and Missouri is one of 19 states that has not yet taken steps to expand coverage.

Because subsidies are only available in the exchange for people whose household incomes are at least 100 percent of poverty (since Medicaid was supposed to be available for those below that level), there are 96,000 people in Missouri who are in the coverage gap and have no realistic access to health insurance.  They aren’t eligible for Medicaid or for subsidies to offset the cost of private insurance.

The 2017 legislative session: dueling bills seek to expand Medicaid or convert it to a block grant

The 2017 legislative session in Missouri started on January 4. Two bills were introduced that day, with very different agendas:

S.B.70, introduced by Senator Jill Schupp (D, 24th District), calls for the expansion of Medicaid as called for in the ACA, effective January 2018. It’s highly unlikely that Schupp’s bill will advance, given that Republican control the Missouri legislature, and that Donald Trump’s win has emboldened their rejection of the ACA — including Medicaid expansion.

S.B.28, introduced by Senator David Sater (R, 29th District), calls for Missouri to submit an application to CMS for a “global waiver” for Medicaid, which would allow the state to receive Medicaid funds under a block grant, rather than the current open-ended matching system that the federal government uses.

S.B.28 calls for the state’s global waiver proposal to include a request that the block grant be “adjusted for inflation, state gross domestic product, state population growth, state Medicaid population growth, and other economic and demographic factors.” This is an effort to protect the state from running out of Medicaid funding part-way through the waiver demonstration. Currently, the U.S. territories have Medicaid block grants, and Puerto Rico is in danger of running out of funds nearly two years before the end of their current funding period, and 900,000 Puerto Ricans could lose coverage as a result.

Vermont and Rhode Island have global waivers, but neither is a block grant (here’s more about Vermont’s, and here’s more about Rhode Island’s). A global waiver requesting a block grant structure would have been extremely unlikely to be approved under the Obama Administration, but could very well be approved under the Trump Administration.

Sater’s legislation seeks to allow the state to have greater flexibility over who’s covered under the program, It suggests that the global waiver could include work requirements for able-bodied adults, and “initiatives to promote healthy outcomes and reward personal responsibility,” including copays, premiums, and the use of HSAs.

The impact of the 2016 election

Governor Jay Nixon, a Democrat who pushed for Medicaid expansion in Missouri since 2012, was term-limited, and could not run in the 2016 election (although he has said he’ll continue to advocate for Medicaid expansion after leaving office). Former US Navy SEAL Eric Greitens (a former Democrat, now a Republican), won the election, and has said that he was opposed to Medicaid expansion because of the cost to the state.

But more importantly, Donald Trump’s win has cast a cloud of uncertainty over the future of the entire ACA, including Medicaid expansion. The GOP’s plan to repeal and replace the ACA started moving forward in earnest in mid-January 2017, when Congress passed a budget resolution that calls for legislative committees to begin drafting legislation to repeal the ACA.

House Speaker Paul Ryan has said that there’s likely to be a significant delay before an ACA replacement is implemented. But it’s unlikely that additional states would be likely to move forward with Medicaid expansion under a Trump Administration.

Who is eligible?

In addition to the aged, blind, and disabled, the following populations are eligible for MO HealthNet Medicaid in Missouri:

  • Adults without dependent children are not eligible at all (this is generally the case in states that have not expanded Medicaid) unless they’re disabled.
  • Adults with dependent children are only eligible if their household income doesn’t exceed 18 percent of poverty level.  This is about $3,562 a year for a family of three; only Texas has a more stringent guideline, at 15 percent.
  • Infants under one are eligible for Medicaid if their household income is up to 196 percent of poverty.
  • Children 1 – 18 are eligible if their household income is up to 150 percent of poverty.
  • Children above the Medicaid income thresholds are eligible for CHIP if their household incomes are up to 300 percent 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 percent of poverty.

How do I enroll?

2014-2016 enrollment numbers

From October 2013 through April 2014, 45,513 applicants in Missouri enrolled in Medicaid or CHIP.  They were already eligible for Medicaid under the existing guidelines, but had not enrolled prior to the opening of the ACA exchanges.

During the second open enrollment period (November 15, 2014 to February 15, 2015), 34,679 people enrolled in Medicaid/CHIP through the Missouri exchange.

Medicaid enrollment is year-round, but total enrollment in MO HealthNet decreased by 3.5 percent between September 2013 and August 2014. A spokesperson for the Missouri Department of Social Services said that enrollment had been trending downward for some time.  But by October 2016, total enrollment in MO HealthNet had grown to

But by October 2016, total enrollment in MO HealthNet had grown to 975,708 people – an increase of 15 percent since the fall of 2013. This increase in enrollment — despite the fact that the state hasn’t changed their eligibility guidelines — is known as the “woodworker effect,” as people already eligible for Medicaid came “out of the woodwork” due to the increased outreach and advertising that went along with the implementation of the ACA’s exchanges.

In 2013, 13 percent of Missouri’s population was uninsured, according to U.S. Census data. The state’s uninsured rate fell slightly to 11.7 percent in 2014, and dropped again to 9.8 percent by 2015. There is no doubt however, that Medicaid expansion would drive that number significantly lower.

Missing 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 state gradually starts to pay a share of the expansion cost, but never more than 10 percent.  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.

From 2013 through 2022, if Missouri continues to reject Medicaid expansion, the state will give up $17.8 billion in federal funding, assuming the ACA’s Medicaid expansion remains in place (that’s unlikely with a Trump Administration and Republican Congress, but it’s helpful for putting the funding into perspective).

And because residents in states not expanding Medicaid still have to pay federal taxes, Missouri residents have been paying for Medicaid expansion in other states since 2014. By 2022, people in Missouri will have paid $7.3 billion in federal taxes used to pay for Medicaid expansion in other states.

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 unless the state accepts federal funding to expand Medicaid, the hospitals will still be treating significant numbers of uninsured patients.  As a result of Missouri’s decision to opt out of Medicaid expansion, hospitals in the state are projected to lose $6.8 billion between 2013 and 2022.

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.

Outgoing 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 are 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 percent of the poverty level. It was estimated that expansion of Medicaid would make coverage available to 300,000 uninsured Missouri residents (this is smaller than the Families USA number cited above, because people with incomes between 100 percent and 138 percent of the poverty level were already eligible for subsidies in the exchange, and many of them have availed themselves of that opportunity; they are not uninsured but they would be newly-eligible for Medicaid — and the lower cost-sharing that it entails — if coverage were to be expanded).

Several other similar bills were introduced during the 2015 session aswell, 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, 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 means that hospitals are having to cut costs, and in June 2015, Mercy Hospital announced 127 job cuts in Springfield.

Missouri Medicaid

How to apply

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

Who is eligible

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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