Missouri and the ACA’s Medicaid expansion

Medicaid expansion will be on the August 4, 2020 primary ballot in Missouri, giving voters a chance to decide an issue that state lawmakers have long rejected

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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 22 percent of the poverty level. Only Texas and Alabama have lower Medicaid eligibility caps, at 18 percent.

113,000 in the coverage gap

If Missouri were to expand Medicaid, an estimated 230,000 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 14 states that have not yet expanded coverage (Nebraska is counted among the states that have expanded coverage, although their coverage expansion doesn’t take effect until October 2020).

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 an estimated 113,000 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.

Medicaid expansion initiative will be on the 2020 ballot in Missouri, but the governor opted to put it on the August 4 primary ballot instead of the general election ballot

Voters in Missouri will get to determine whether Missour expands Medicaid. The question will be on the August 4, 2020 primary ballot.

In the last few years, voters in Maine, Idaho, Nebraska, and Utah have approved Medicaid expansion ballot initiatives (and voters in Oklahoma will have an opportunity to do so on the June 2020 primary ballot). As a result, Medicaid has already been expanded in Maine, Utah, and Idaho, and will be expanded in Nebraska as of October 2020.

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. At that point, a citizen-led effort to get Medicaid expansion on the ballot in Missouri was considered a non-starter, as it didn’t have the backing of any major groups at that point.

But in 2019, things were different. Healthcare for Missouri has 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 early September 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” last fall.

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, have noted that they believe Parson is choosing to put the measure on a ballot for an lower turnout election, in hopes that it won’t pass. Oklahoma Medicaid expansion advocates also gathered enough signatures to get an expansion initiative on the ballot in 2020, but Oklahoma’s governor — who is opposed to Medicaid expansion — also opted to put the ballot initiative on the primary ballot (the primary election is in June in Oklahoma).

Parson has made his opposition to Medicaid expansion clear, but he has stated that he will “uphold the will of the people” if the Medicaid expansion ballot initiatve is passed by voters. The Kansas City Star Editorial Board noted ion 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.

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. So while Parson has committed to not blocking Medicaid expansion if voters approve it (ie, the way former Maine Governor Paul LePage did), there is no guarantee that Medicaid expansion will be implemented exactly in the manner described in the ballot initiative, even if it’s passed by voters.

2018 legislation: Medicaid expansion was a non-starter; lawmakers considered a Medicaid work requirement

Medicaid expansion was not considered by Missouri lawmakers during the 2019 legislative session. But SB713, introduced in the 2018 session, would have expanded Medicaid eligibility to include adults with income up to 138 percent of the poverty level, as called for in the ACA, with an effective date of January 2019. It did not advance out of committee.

On the other end of the spectrum, lawmakers in Missouri also considered SB948, which would have required some of the people who are already eligible for MO HealthNet to work (or participate in community service, job training, etc.) at least 80 hours per month in order to retain eligibility. This bill also stalled in committee. But if it had passed, most MO HealthNet members would have been exempt, as most are already disabled, children, elderly, or pregnant. Missouri does not allow non-disabled, childless adults to enroll in Medicaid, regardless of how low their income is. And parents with dependent children are only eligible for Medicaid with income up to 22 percent of the poverty level, which amounts to about $381 per month for a household of three people in 2018.

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

Two bills were introduced on the first day of the 2017 legislative session in Missouri, with very different agendas:

S.B.70, introduced by Senator Jill Schupp (D, 24th District), called for the expansion of Medicaid as called for in the ACA, effective January 2018. The bill did not advance, which wasn’t surprising, given that Republicans control the Missouri legislature, and that Donald Trump’s win emboldened their rejection of the ACA — including Medicaid expansion.

S.B.28, introduced by Senator David Sater (R, 29th District), called 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 also did not advance in the 2017 session.

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 potentially be approved under the Trump Administration.

Sater’s legislation sought to allow the state to have greater flexibility over who’s covered under the program, It suggested 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

Former 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 said he would 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 is opposed to Medicaid expansion because of the cost to the state. Greitens continues to cite what he calls an “explosion” in government health care spending in the state, but health care experts in Missouri note that the spending growth has actually been fairly modest.

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 22 percent of poverty level.  This is about $381 a month for a family of three; only Texas has a more stringent guideline, at 18 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?

Enrollment numbers

From October 2013 through April 2014, 45,513 HealthCare.gov 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 January 2018, total enrollment in CHIP and MO HealthNet had grown to 959,354 people – an increase of 13 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, and to 8.9 percent by 2016. 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 states gradually started to pay a share of the expansion cost, but the states’ portion will never be 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 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 means that hospitals are having 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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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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