The Missouri Supreme Court has weighed in on Medicaid expansion. The court determined the state’s initiative petition to expand Medicaid was in fact constitutional. The decision reverses the Cole County Circuit Court’s finding and paves the way for those newly eligible to begin enrolling in the coming days. The court’s opinion is an unfortunate blow for those of us worried about the extraordinary taxpayer costs that will accompany expansion. But there’s reason to believe Missouri’s fight over Medicaid funding is not over quite yet.

In last month’s lower court ruling, Cole County Circuit Judge Jon Beetem found the initiative expanding Medicaid unconstitutional because it failed to include a funding mechanism. As I’ve written before, a constitutional amendment that requires new state expenditures should include measures for funding the expenditures. In my opinion, absent such a requirement, an amendment would infringe on the constitutionally delegated power of Missouri’s legislative branch to appropriate state spending. The state supreme court disagreed, but with one huge caveat.

The court ruled that the amendment doesn’t violate the constitution because it doesn’t specifically appropriate funds. In other words: Missouri’s constitutional amendment can require the state’s Medicaid program to enroll those eligible under expansion, but it can’t compel the legislature to appropriate the funds necessary to cover their costs.

If this sounds confusing, that’s because it is. Missouri’s highest court in the land drew a fine line to determine constitutionality but left obvious and important questions unanswered. The legislature thought its refusal to include expansion funding in this year’s budget meant the policy wouldn’t be implemented, but Missouri’s Medicaid budget lines do not include language indicating who the funds cover. As a result, the court concluded the budgeted funds are available to all who are eligible and that would include those covered by the expansion. The decision means that Missouri must start incurring new costs despite not having a plan to pay for them. Until the legislature acts, the cost of covering new enrollees will need to be paid for out of funds specifically set aside for those currently enrolled in Missouri’s program. If this occurs, the Medicaid program will run out of budgeted funds much sooner than anticipated.

So, what should the legislature do? The supreme court’s decision appears to give legislators the authority to continue refusing to provide funding for expansion. Not providing funding for new enrollees would likely require amending the current budget to make clear that the already approved Medicaid budget lines do not apply to expansion enrollees. This action could lead to another court challenge. Lawmakers could also choose to approve expansion funding. But where will the money come from? That’s the multibillion-dollar question. Even though the federal government has currently agreed to pick up 90 percent of the billions in expected expansion costs, all spending needs to be appropriated, and Missouri’s share would still be significant.

It will be interesting to see what our elected officials decide regarding funding the state’s Medicaid program going forward. It seems safe to say there won’t be any easy answers.