Even though a federal judge in Texas struck down the Affordable Care Act late last year, Medicaid expansion could be a Missouri legislative session issue that gets more attention than in the past. The reason for an uptick in interest, if it’s to come, would likely be connected to November election results in which voters in three Republican-leaning states, including to one adjacent to Missouri, passed the expansion which is part of the health care law.

Only three of the eight surrounding states will have failed to expand Medicaid to cover able-bodied low-income people between 19 and 64 years old who earn up to 138% of the poverty level.

Senator Scott Sifton (D-Affton)

Democratic Senator Scott Sifton of Affton, who has submitted Medicaid expansion bills in the past, filed a measure this year to send the issue before Missouri voters. He believes the Republican supermajority in the legislature that has rejected enlarging the federal healthcare program in the past can be persuaded into embracing a ballot measure.

“I would hope so,” said Sifton. “The coalition in support of Medicaid expansion has always been a bipartisan coalition. There have been folks from across the political spectrum who have supported getting this done, and frankly, that’s the reason it’s happened in 37 states.”

Fellow Democratic Senator Jill Schupp of Creve Coeur files Medicaid expansion bills on a yearly basis.  She also filed a measure in December which would require voters to weigh in on the subject. Both the Sifton and Schupp proposals would place the issue on the ballot in November 2020.

Sifton is unfazed by the federal judge’s decision in Texas to overturn the Affordable Care Act, noting his ruling stands in conflict with previous Supreme Court renderings supporting the law.

“This is one judge’s ruling,” said Sifton.  “I don’t believe that that ruling stands up at the end of the day.  And there’s a long way to go before that’s holding of nationwide implication.”

House Democrat Deb Lavender filed two Medicaid bills for this session, one to move through the legislative process and the other to bring expansion to the ballot. But she’s not expecting Republicans to allow the electorate to weigh in on the issue, especially after voters resoundingly rejected one of the majority party’s long-held priorities in August – making Missouri a right to work state.

“The legislature is not looking to put these things in front of our people I think for fear it will pass,” Lavender.

State Rep. Deb Lavender, D-Kirkwood, speaks to Capitol reporters on March 15, 2018 (photo courtesy of Tim Bommel at House Communications)

Still, the physical therapist and owner of an outpatient Physical Therapy clinic believes Medicaid expansion supporters in the legislature are becoming increasingly emboldened, especially since her first term as a state lawmaker in 2014.

“You could not use the term Medicaid expansion on the floor that everybody didn’t take a deep breath and say ‘Oh my goodness, somebody just almost said a cuss word on the floor’, that it was such a hot potato,” Lavender said.

The representative from Kirkwood isn’t changing her approach to legislation based on the recent federal court decision, contending the judge in the case, Reed O’Connor, was biased against the law and would be overruled.

“It occurs that perhaps he allowed his personal opinion to cloud his legal opinion,” said Lavender.  “And I’ve already heard many people say they don’t feel that his ruling will hold up at all.”

Lavender attempted to attach an amendment to expand Medicaid to a bill during a special session of the legislature last year.  The legislation to broaden the use of treatment courts as an alternative to criminal charges for certain offenders included language pertaining to Medicaid.  But Lavender’s amendment was deemed out of order and rejected as not being in the scope of the governor’s call for a special session which was specific as it related to treatment courts.

Three Democratic House members filed Medicaid expansion bills in the last legislative session. One from Peter Meredith of St. Louis would have sent the issue before voters. One by Gina Mitten of St. Louis called on lawmakers to pass a bill. A third one from Michael Butler of St. Louis also required lawmaker approval but, in addition, included a provision for adult Medicaid recipients not enrolled in Medicare to receive the same health care insurance as state employees.

The Butler proposal further included language favored by Republicans calling for the state to seek a waiver to deviate from federal government requirements. GOP Senator David Sater of Cassville has submitted legislation for such waivers in the past to apply to the existing Medicaid structure in Missouri.

In December, Sater pre-filed two measures relating to Medicaid. One would seek a waiver to allow for work requirements for most adult recipients under 65 years old. The other would apply for a work requirement waiver as well as the ability to charge enrollees for co-payments and premiums.

House Republican Curtis Trent of Springfield sponsored a bill last year and pre-filed a measure in December also calling for the state to seek a waiver to place work requirements on recipients.

Medicaid expansion was a component of the Affordable Care Act (ACA) passed by Congress during the Obama administration but was stripped away by the Supreme Court in 2012.  The high bench upheld the constitutionality of the ACA’s individual mandate, which required most people to maintain health insurance coverage, but found the Medicaid expansion portion too intrusive on states.

Since that time, states have increasingly chosen to expand the federal healthcare program on their own as the Supreme Court decision left the option open.

The number of states opting in grew from 33 to 36 plus the District of Columbia in the recent general election when voters in Nebraska, Utah, and Idaho, three red states, passed ballot measures to implement the expansion.

Kansas, Oklahoma, and Tennessee are the only holdouts among the eight states that border Missouri, and Kansas could be changing soon if history replays itself.

Kansas lawmakers passed Medicaid expansion in 2017, but then-Governor Sam Brownback vetoed it and the legislature didn’t have enough votes to override the veto.   A similar measure failed to advance during the state’s 2018 legislative session, although it passed one chamber.  Newly-elected Democratic Governor Laura Kelly, who has take office, supports Medicaid expansion, and has vowed “to advocate for and sign legislation to expand Medicaid in her first year.”

If Kansas follows through on Kelly’s pledge, Missouri and 12 other states, mostly in the south, would become more pronounced outliers.

Republican lawmakers in Missouri contend the expense of Medicaid expansion would be far too costly for the state.

If implemented, expansion in Missouri would carry a $2 billion price tag with 90% of the cost covered by the federal government. At 10%, Missouri would have to chip in $200 million annually.  FamiliesUSA estimates that 293,000 people would be newly eligible for coverage if the state were to expand the program.

Senator Sifton contends money is being lost by employers and the state without Medicaid expansion.

“When you talk about patients who by definition are of working age, between 19 and 64, failing to get people good preventative care is going to result in missed work time,” Sifton said. “It’s going to result in lost revenue for employers, and frankly lost revenue for the state.”

In addition to filing two Medicaid expansion bills, Representative Lavender submitted a measure she claims would finance the cost of enlarging the federal program. It would take advantage of a Supreme Court decision in June that opened the door for states to start taxing internet sales from out of state companies.

“Missouri is not set up or established to collect that internet sales tax on purchases made from Missourians,” Lavender said.

Her proposal would call on out-of-state sellers with no physical presence in Missouri to collect and tax money to the state. The Supreme Court ruling did away with a more than 25-year-old law prohibiting such taxes from interstate purchases unless the seller has a physical presence in a state, like a warehouse or an office.

Senator Sifton remains convinced that Republicans, who control the legislature, will have a hard time denying a public vote on Medicaid expansion.

“It’s a bipartisan idea whose time has come, and Missouri voters ought to have the opportunity to weigh in on whether they want Medicaid expansion for their state,” said Sifton.

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