Medicaid’s Checkup: Part 2

In this post on my series about Medicaid in Missouri, I want to dive deeper into the effects of Medicaid expansion.

Missouri voters approved Medicaid expansion as a constitutional amendment in August of 2020, during the height of the COVID-19 pandemic. Due to legal challenges and various technical issues, expansion-eligible Missourians didn’t begin joining the program until October of 2021. As I stated in part one of this series, because of COVID’s impact on the program as well as the federal rules accompanying the increased funding, it’s been nearly impossible until now to fully analyze the rollout of Medicaid expansion.

Before voters weighed in on the measure, expansion supporters made several claims about how the policy would impact Missouri. At the time, I wrote repeatedly about three of their key claims with which I disagreed. First, they estimated that fewer than 250,000 people would enroll within the first year. Second, they said the expansion enrollees would be “newly eligible” for the program, which is something the federal government requires as a condition of receiving extra federal funding. And third, they said the expansion wouldn’t cost state taxpayers any money. In fact, they argued it would save money. Unfortunately, none of these projections came true.

As I also mentioned in part one of this series, prior to the pandemic, Missouri’s Medicaid enrollment was around 850,000, with about 520,000 of those being kids. Within one year of expansion being implemented (October 2022), Missouri’s Medicaid enrollment had ballooned to 1.4 million with 288,000 adults in the “newly eligible” expansion population. Today, with COVID safely in the state’s rearview mirror, program enrollment is still nearing 1.3 million total with 340,000 adults enrolled as a result of the expansion of eligibility requirements. The only Medicaid eligibility category that has seen a decline in recent years is that of people with disabilities—but that is a topic I’ll discuss in greater detail in the next post in this series.

To quickly summarize the impact of expansion thus far, enrollment has exceeded projections by around 35 percent, and current program costs are approximately 75 percent ($7.8 billion) higher than they were in 2019. The prediction that Medicaid expansion would be costless relied on Missouri being able to shift a significant portion of its costs to the federal government, which would in turn have saved state taxpayers money. Thus far, this has not been the case as Missouri taxpayers’ contribution to the state’s Medicaid program has grown by 74 percent ($1.6 billion) over the same period.

While hindsight is 20/20, it’s fair to say that the current problems with Missouri’s Medicaid program were predictable four years ago. Further, there’s no longer any reason to think today’s data represent anything other than the new normal for the program. It’s time to accept that Missouri voters were sold a bill of goods on Medicaid expansion, and it’s incumbent on our state’s elected officials to explore whatever actions are possible in the coming years to fix the problems that expansion has created.