Missouri Supreme Court Upholds Ballot Initiative’s Medicaid Expansion

July 23, 2021
In a unanimous ruling, the seven justices of the Missouri Supreme Court pushed aside arguments from the Missouri General Assembly and validated an August 2020 ballot initiative expanding Medicaid in that state

The refusal of the majority leaders in the Missouri General Assembly to implement the Medicaid expansion approved by voters in an August 2020 ballot initiative was contradicted on June 22, when the Missouri Supreme Court ruled unanimously that the state’s legislature must move forward to expand Medicaid health insurance coverage for that state’s low-income residents.

As Courthouse News’ Rox Laird wrote on Wednesday evening, “The Missouri General Assembly had previously approved funding for only limited categories of Missouri residents, but the ballot initiative approved by Missouri voters in August 2020 amended the state constitution to require the state to cover a new category of eligible Missouri residents, including adults aged 19 to 64 whose income is at or below 138 percent of the federal poverty level. This would cover an estimated 275,000 additional residents. Because the Missouri Legislature failed to appropriate sufficient funds for the Medicaid expansion, the state did not implement the expansion in March, as required in the constitutional amendment,” he noted.

As a result of the General Assembly’s refusal to implement the expansion, three Missouri residents who would be eligible under the expansion sued the state, challenging the refusal by the Department of Social Services to expand coverage because of a lack of funding. Cole County Circuit Judge Jon Beetem struck down the voter-approved Medicaid expansion on June 23, finding the referendum was unconstitutional because it lacked a funding mechanism. The case was immediately appealed to the state’s high court. But as Laird wrote, “On Thursday, the justices, sitting en banc, reversed the trial judge in a 14-page per curiam decision and remanded the case to the lower court to enter a judgment for the plaintiffs, including a determination of appropriate injunctive relief.”

Meanwhile, the St. Louis Post-Dispatch’s Kurt Erickson wrote that, “Moving with uncharacteristic speed, the high court overruled Cole County Circuit Judge Jon Beetem’s decision that upended the long-running push to add as many as 275,000 low-income Missourians to the government-run health insurance program. In doing so, the court called Medicaid expansion “valid,” paving the way for the Missouri Department of Social Services to resubmit an application to the federal government outlining its plan to serve the additional enrollees,” Erickson wrote. And he quoted attorney Chuck Hatfield, who had represented the three women who had brought the lawsuit, as saying that “The Supreme Court has now spoken and decided that our clients are eligible for coverage.” As Erickson wrote, “The move puts the state in a position to receive a 90-percent match from the federal government to help pay for the added coverage.”

And Erickson quoted statements from several groups supporting Medicaid expansion in Missouri. “As a result of the Supreme Court’s ruling, Missourians across the state will finally be able to realize the health and economic benefits of Medicaid expansion. State after state has shown that in addition to providing insurance to those eligible, expansion is a fiscal and economic boon to state economies and budgets,” said Amy Blouin of the Missouri Budget Project.

And Caitlyn Adams, executive director of Missouri Jobs for Justice, said, “This decision restores faith in our democracy and that the power of the people will continue to prevail over political grandstanding. For more than a decade, we have called upon lawmakers in Jefferson City to do the right thing and expand Medicaid,” said Caitlyn Adams, executive director of Missouri Jobs for Justice.

A post by the St. Louis-based Missouri Foundation for Health applauding the ruling stated that, “In August of 2020, a substantial majority of Missouri voters approved an amendment to ingrain Medicaid expansion into the state’s constitution. Today, in a unanimous decision, the Missouri Supreme Court reaffirmed the will of the people by ruling that the state has an obligation to expand Medicaid eligibility. The verdict makes clear that Missourians who qualify under expansion have a constitutional right to Medicaid, and we applaud the court’s decision. Though this is cause for celebration, there remains a tremendous amount of work to be done to ensure that those who are newly eligible are able to apply.” The Missouri Foundation for Health notes on its website that “Our mission [is] to eliminate underlying causes of health inequities, transform systems, and enable individuals and communities to thrive.”

And the Missouri Foundation for Health’s president and CEO, Dwayne Proctor, M.D., stated that “Today’s supreme court decision to move forward with Medicaid expansion was the right thing to do for Missouri. It’s right because expansion will improve the health of hundreds of thousands of Missourians, and if that wasn’t reason enough, it’s also an economic win for our state. It’s right because the people have spoken, and a majority of Missouri voters said loud and clear that they support Medicaid expansion. This ruling confirms that Missourians who qualify under expansion have a constitutional right to Medicaid coverage. This marks a significant step toward achieving health equity and ensuring that individuals and families have access to affordable, high-quality health insurance,” Dr. Proctor said. “We look forward to working with our state’s leaders and committed partners to move ahead with full implementation. Our next step is to ensure that those who are eligible know about expansion, how to enroll, and where to access care. On behalf of all Missourians, we’d like to thank the numerous leaders and organizations who have worked alongside us to make it to this historic moment. We look forward to more collaborations with them and others as we strive to build a more equitable future.”

With regard to the legal substance of their ruling, the seven state supreme court justices said that the their state’s constitution prohibits only initiatives used for the “appropriation of money,” including an initiative that “deprives the General Assembly of discretion and requires it to appropriate money for the initiative’s purposes.” An initiative “that simply costs money to implement does not necessarily require the appropriation of funds so long as the General Assembly maintains discretion in appropriating funds to implement that initiative,” the justices wrote.

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