Another Crack at Expansion?
Earlier this week, Missouri’s legislature moved one step closer to sending another question to Missouri voters regarding Medicaid expansion. This time though, the ballot question won’t be about expanding Medicaid eligibility. The question this time is about how much flexibility the state’s elected officials should have administering the state’s Medicaid program.
Over the past few years, my colleagues and I have written a lot about Medicaid expansion and the problems it presents for Missouri. Before voters approved the Medicaid expansion ballot measure in 2020, I wrote repeatedly about how costly expanding eligibility would be for our state, despite the ballot language suggesting the measure could somehow save money. In addition, I discussed how administratively difficult it would be to grow an already oversized program, and what that could mean for other state funding priorities.
After expansion passed, there was a long legal battle about whether the ballot initiative required the legislature to fund Medicaid expansion. In short, some legislators argued that since the expansion initiative failed to include a way to pay for the costs incurred by expansion, it was their prerogative to decide whether to pay for expansion at all (because the constitution gives the legislature exclusive authority to approve all state spending). The state supreme court disagreed and ruled that the legislature was required to find the money necessary to cover the cost of expansion. Administering the state’s largest program is more difficult than just writing a check, so the legislature now appears ready to ask voters for additional input on how they think Medicaid should be run—thus a new ballot initiative.
So far, the legislative effort is focused on three separate Medicaid issues. First, should Missouri impose work requirements for able-bodied enrollees in the expansion population? Second, should Missouri continue paying medical bills for individuals who live outside of our state boundaries? And third, should the legislature have the flexibility to decide how much money can be spent on Medicaid expansion annually, or does the program really have a “blank check”?
Since Medicaid is a partnership with the federal government, it’s not clear how easy each of these changes would be to implement, as they’d likely require federal approval as well. But I do believe additional flexibility would represent a major step forward for Missouri’s Medicaid program. And as far as I know, Missouri voters have never weighed in on these three issues before, so it will be interesting to see if they agree.