Missouri and the ACA’s Medicaid expansion

Voters approve constitutional amendment to expand Medicaid

Constitutional amendment to expand Medicaid was approved by voters in August 2020 election

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Although the federal government began providing funding to expand Medicaid in 2014, Missouri is one of 13 states that has thus-far rejected Medicaid expansion. But that will soon change, thanks to a constitutional amendment that voters approved in the August 2020 primary election. The measure passed by a margin of about 53 to 47 and calls 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.

An estimated 230,000 people are expected to be newly eligible for coverage under the expansion of Medicaid in Missouri. Coverage will be available to adults up to age 64 if they have an income that doesn’t exceed 138 percent of the poverty level. In 2020, that amounts to about $17,609 for a single individual, and $36,156 for a household of four (children are already eligible for Medicaid at higher income levels).

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, after state lawmakers and the governor had previously rejected the idea of Medicaid expansion.

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, but Oklahoma’s governor — who is 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.

Parson has 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.

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.

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

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 was one of 13 states that had not yet expanded coverage (Nebraska and Oklahoma are counted among the states that have expanded coverage, although their coverage expansions have not yet taken effect as of August 2020). Now that voters in Missouri have approved a constitutional amendment to expand Medicaid, coverage should be available to low-income adults in the state by mid-2021.

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. This will continue to be the case until the state’s new Medicaid expansion provision takes effect.

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 also considered SB948, which would have required some of the people who are already eligible for Missouri Medicaid 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. If it had passed, most Missouri Medicaid enrollees would have been exempt, as most are disabled, children, elderly, or pregnant (before Medicaid expansion takes effect, low income alone does not make a person eligible for Medicaid in Missouri).

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.

Who is eligible for Medicaid in Missouri?

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

  • 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 (this rule will be relaxed once Medicaid expansion takes effect).
  • 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 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:

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 April 2020, total enrollment in Missouri Medicaid and CHIP grew by about 5 percent, and stood at 887,443 people in the spring of 2020. This was lower than it had been two years earlier; as of early 2018, enrollment was about 13 percent higher than it had been in late 2013.

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, 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, Missouri was projected to give up $17.8 billion in federal funding by not expanding Medicaid. That number will end up being a little lower, however, since Medicaid expansion is expected to take effect at some point in 2021.

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.

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 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 percent 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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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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