Missouri Medicaid expansion hangs in the balance as state Supreme Court hears arguments

Galen Bacharier
Springfield News-Leader
The Missouri Supreme Court building in Jefferson City.

JEFFERSON CITY — The Missouri Supreme Court heard arguments in the state's Medicaid expansion case Tuesday, as the high court weighs whether to expand the low-income health care program for roughly 275,000 Missourians. 

The court's seven judges heard arguments from attorneys representing three women suing to be included in the state's Medicaid program, the expansion of which was approved by a majority of Missouri voters last year. The state has maintained that since money for expansion was not included in the budget by the legislature this year, the women and others who would qualify are not eligible.

Attorney Chuck Hatfield, representing the three women appealing a lower court ruling, argued that since the legislature funded all of the services that qualify under Medicaid in this year's budget, his clients are eligible. He called a June circuit court ruling an "unprecedented step" of holding a provision of the Missouri Constitution — the voter-approved Amendment 2 — unconstitutional.

"Despite an appropriation and despite the plaintiffs' stipulated eligibility, the state defendants refuse to enroll them in the program," the attorneys wrote in their brief to the court, submitted Monday.

Background:Circuit judge rules Missouri is not required to expand Medicaid

In both his written brief and oral arguments to the court Tuesday, Hatfield cited a 2020 decision involving Planned Parenthood that said it was illegal for the legislature to use a spending bill to amend a "substantive law." The state, in its brief and oral arguments to the court, has requested that the court overturn that ruling.

That decision "lacks support in the plain language of the Constitution" and "rests on shaky jurisprudential footing," Solicitor General John Sauer wrote. He argued Tuesday that the intention of the legislature this year regarding Medicaid expansion was clear, despite its approval by voters.

"There's no mystery what the legislature was doing," Sauer said. "It was one of the most intensive debates in the history of the General Assembly. There were attempts to fund Medicaid expansion in four different bills, plus multiple amendments, and at the end of that, every single one of those attempts was rejected."

Speaking to reporters after the hearing, Hatfield said he disagreed with that argument, saying that "you don't look at failed bills" to determine a case of this nature.

"I'm struggling to find any case law that does so," he said.

Background:Three women sue Missouri, seeking Medicaid coverage

The court asked few questions of either side, which Hatfield said was "not unusual," but Judge W. Brent Powell did question Sauer on what the case might mean for future ballot petitions.

"How is it that we can now look back at an election on an amendment that was passed and decide that it was invalid, and if so, how long can we continue to do that?" Powell asked. "Can we go back and look at medical marijuana and decide that was passed invalidly?"

Sauer said the state's position was to preserve Amendment 2, the amendment that expanded Medicaid — leaving open the potential for the court to rule that it is valid but not force the state to fund and enroll the additional population. Hatfield said he thought such a ruling was possible, but unlikely.

275,000 low-income Missourians await the Medicaid case's outcome

The case is one of the highest-stakes legal battles in recent Missouri history. It will determine whether roughly 275,000 low-income Missourians receive benefits and services under MO HealthNet, the state's Medicaid program. The high court's ruling could also impact the process of future petitions for voter approval.

There is not yet a clear timeframe for when the court will issue its decision, but Hatfield said he expected it to come relatively quickly given the "breakneck speed" of the case so far. The process has been expedited primarily due to the fact that those who qualify under expansion would have been enrolled in the program on July 1.

In June, Cole County Circuit Judge Jon Beetem ruled that Amendment 2 was unconstitutional because it did not specifically designate money with which to pay for the costs of expanding Medicaid. Those suing the state appealed the case directly to the high court, and Hatfield argues that the lower court "refused to adjudicate the question in front of it."

The uncertain future of Medicaid expansion makes Missouri an oddity — it is the only state in the country to have approved Medicaid expansion but not implemented it. To date, 39 states including Washington, D.C. have approved expansion, and 12 have not. 

More:Which Missouri health care and business groups are supporting Medicaid expansion?

In August 2020, 53 percent of Missouri voters approved Amendment 2, which expanded the Medicaid program to include those ages 19-65 earning less than $17,774 annually per individual or $37,570 for a four-person family, which includes an estimated 275,000 people.

The cost of expansion, according to Beetem in his lower court ruling, would be over $1 billion, primarily covered by federal dollars. Gov. Mike Parson, in his proposed budget to lawmakers this year, recommended more than $1.5 billion to fund expansion, but lawmakers declined to include that funding in their final budget.

The most vocal opponents of expansion have been Republican lawmakers in both chambers who represent districts that voted against the 2020 amendment. They have been met with criticism by Democrats and advocates, who have argued that the supermajorities should listen to the majority of voters and fund expansion.

More:Lawmakers push for forgiveness on unemployment overpayments as Missouri considers waivers

The three women suing the state, according to court documents and their attorneys, suffer from health conditions ranging from skin conditions to diabetes and require Medicaid enrollment to seek adequate care.

A number of groups across the state — including lawmakers, health care organizations, clinics and business groups — submitted "friend of the court" briefs in recent weeks, backing either the three women or the state in the monumental case.

Galen Bacharier covers Missouri politics & government for the News-Leader. Contact him at gbacharier@gannett.com, (573) 219-7440 or on Twitter @galenbacharier.