Missouri Medicaid expansion: What is it, what's the cost and why is it controversial?

Apr. 29—What is Medicaid expansion?

Medicaid is a federal program administered by states that provides health coverage to low-income individuals and people with disabilities. The Affordable Care Act expanded eligibility for the program to those earning up to 138 percent of the federal poverty level, or $26,500 a year for a family of four.

A 2012 U.S. Supreme Court ruling allowed states to opt out of expansion, however, leading to debates in statehouses across the country. In states without expansion, individuals who make too much to enroll in Medicaid but less than 138 percent of the federal poverty level fall into a "coverage gap" where they don't qualify for subsidies to help pay for health insurance.

Voters approved an amendment to the state constitution in August requiring Missouri to expand eligibility beginning this summer. Up to 275,000 people are expected to enroll.

Who pays for it?

Under the Affordable Care Act, the federal government picks up 90 percent of the cost of expansion and states pay the remaining 10 percent.

Expansion could cost Missouri an additional $130 million dollars a year.

The American Rescue Plan passed earlier this year provides additional financial incentives for states that have not yet expanded, meaning that Missouri could qualify for up to $1 billion in additional aid over the next two years, according to estimates.

What are the main arguments for and against it?

Expansion supporters say health coverage is not only a moral imperative but a policy with long-term benefits, such as improved health for the previously uninsured. It will help financially-strained hospitals by reducing the amount of uninsured care they provide and could even pay for itself by decreasing the need for other government spending.

Opponents say the program could prove costly and creates a new, ongoing financial obligation. They also warn that the federal government could one day reduce or eliminate its share of the costs, creating a large financial burden for the state. They say individuals should instead be directed toward private insurance and that expansion could encourage healthy adults to not work.

I thought Missouri voters approved expansion. Why is its implementation in doubt?

The Missouri constitution states that only the legislature can direct the state to spend money, not voters via ballot initiative. Because the ballot measure did not include a funding source, Republican lawmakers who have long been opposed to expansion and who control spending, have argued the decision is still up to them.

Without the additional $130 million in state and $1.4 billion in federal funds that Gov. Mike Parson's office proposed to spend on the expansion, the state's Medicaid program would not have enough money to serve everyone who is eligible beginning July 1.

Without the additional funding, Parson's administration could decide to block the newly eligible from enrolling, which would run afoul of the state constitution and land the state in court. It could also enroll the new population, and return to a disapproving legislature to ask for more funds.

Any outcome that doesn't end with funding expansion is likely to end in litigation.

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