Patrick Ishmael
I have related my concerns about a Medicaid expansion in Missouri many times. Not only does Medicaid provide low-quality care to patients, but expanding the program without establishing a plan to pay for the services is simply short-sighted and irresponsible. Here are a few of my specific concerns and criticisms:

  • The expansion is not a "jobs program." It is a mortgage imposed on the future incomes of our children and grandchildren to provide services today that we cannot afford. If the creation or expansion of an entitlement is important enough to pursue, it should be paid out of today's dollars, not tomorrow's.

  • The expansion is not funded. The expansion alone would add nearly $3 billion in new costs to Missouri's annual budgets over the next decade. I have not seen a plan to address that cost. If the absence of a payment plan is not enough of a reason for concern, what happens if future federal budgets, already bathed in the red ink of debt, cause the Feds to dial back their funding on the expansion — raising the state costs further by effectively forcing states to pick up that slack?

  • No, other states would not "get Missouri's money." This is among the more remarkable, and incorrect, claims. Expansion funds are distributed based on enrollment, not on how much Medicaid money is "in the pot" and how many states are drawing on it. If only one state adopted the Medicaid expansion, that state would not receive the funding of the other 49 states. Nor would two states split the Medicaid expansion funding of the other 48 states. And so on.

  • Is Missouri a government that sometimes provides health services, or a health service provider that sometimes governs? If the state expands Medicaid, Missouri's Medicaid program is projected to eat up 38 percent of the state's entire budget. Is this what we want the Show-Me State to be reduced to? A mere vessel of the federal government through which federal Medicaid prerogatives are promoted and administered?

  • The expansion would reinforce an emerging subsidiary relationship between the state and the federal government. Moody's has already downgraded Missouri's credit outlook because the state already relies heavily on federal funding, and will rely even more heavily on it if the state expands Medicaid. Is that the sort of relationship the state wants to promote? Shouldn't the state want to inoculate itself from the consequences of the federal government's spending binge?

While supporters of the Medicaid expansion blithely send legislators Beyoncé Knowles Valentine's Day cards in an attempt to coax policymakers into blowing a multi-billion dollar hole in the state's budgets, it is time for serious policymakers to get serious about this issue. If the Missouri Legislature is going to engage Medicaid this session, it should be to fix what we already have rather than to spend what we do not.

About the Author

Patrick Ishmael
Director of Government Accountability

Patrick Ishmael is the director of government accountability at the Show-Me Institute.