(C) Missouri Independent
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Missouri Republicans couldn’t live with Medicaid expansion. Now they can’t live without it • Missouri Independent [1]
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Date: 2025-04-28
Health insurance for impoverished adults has always been a tortuous endeavor for Missouri.
The legislature fought for years over proposals to expand eligibility for Medicaid, the public health program financed by states and the federal government. Expansion was the subject of some of the legislature’s loudest shouting matches in the years following the 2010 passage of the federal Affordable Care Act.
Missourians finally got tired of watching other states extend health insurance to low-income residents and boast of economic benefits and better health outcomes. They went to the ballot in 2020 and got the job done with a constitutional amendment.
Cue the recriminations. All over again.
After years of gaining public acceptance, Medicaid funding is now endangered in the U.S. Congress, where Republicans are under pressure to find big pots of money to raid in order to pay for President Donald Trump’s tax cut package.
Medicaid is a huge pot of money. And Republicans are eyeing the portion that is used to compensate the 40 states that took advantage of an Obamacare provision to expand eligibility guidelines for low-income adults.
The federal government currently pays 90% of the expansion costs.
Should Congress claw back that money, states in total stand to lose about $600 billion over a decade’s time, according to a recent analysis.
Cuts like that would force all states into difficult corners. But Missouri’s situation would be genuinely strange.
Because, after all of those years spent resisting Medicaid expansion, Missouri now is unable to get rid of it.
At least not easily.
With their bickering and inaction, legislators in Missouri forfeited the chance to enact Medicaid expansion by statute, which could be amended or even repealed if the occasion demanded.
Instead, advocates expanded Medicaid eligibility by amending the state Constitution. Their work can only be undone by passing another amendment, which would be a long, acrimonious process.
And so, for the time being, Missouri would be forced to provide coverage to working-age, low-income adults, even if the federal match shrinks or disappears.
“So you will see cuts in other places,” said Bridgett McCandless, a retired physician who ran a health clinic for uninsured patients and served as CEO of the Health Forward Foundation, which focuses on expanding healthcare access.
“The three groups that are at the greatest risk are pregnant women, children and seniors with disabilities, primarily in nursing homes,” she said. “All that will have profound generational effects.”
Other cuts that wouldn’t violate the constitutional amendment could be reimbursement costs for providers, dental care, mental health and substance use treatment and home health care. Missouri may also be forced to look at cuts outside of its Medicaid program.
Somewhere out there, a class of term-limited Republican Missouri lawmakers nods sagely and says, “told you so.”
Indeed, certain legislators did warn that the state would be on the hook if a capricious future Congress reneged on its commitment to the Medicaid expansion match. It was the most solid argument against broadening the program — much less tedious than the insinuations that the low-income Missourians who stood to gain health insurance were freeloaders and grifters.
Then-Gov. Jay Nixon, a Democrat who wanted to expand Medicaid, proposed including a safety valve in state law: If federal funding was ever cut, Missouri would roll back the expansion.
But no law was passed, and so no safety valve. We are left to argue about whether that is good or bad.
For now, the prevailing strategy seems to be to hope we don’t have to find out.
U.S. Sen. Josh Hawley has turned heads by declaring that he won’t support outright cuts to Medicaid, though he does favor work requirements, which would force some people out of the program.
Hawley, a former Republican Missouri attorney general, has spent all of his political career opposing Obamacare, which includes Medicaid expansion.
What swayed him, he said, was the vote on the constitutional amendment, which was 53% in favor and 46% opposed. Many supporters found that a bit close for comfort, but in an interview with RollCall, a Washington outlet, Hawley called it “a big margin.” He also said he expected Trump to oppose cuts to Medicaid.
Whether that will happen, or whether Hawley will stick to his opposition, is anyone’s guess.
What’s certain is that about 1.3 million Missourians use Medicaid or the federal Children’s Health Insurance Program. That’s about one-fifth of the state’s population.
Of that number, about 300,000 adults have gained access to health insurance since voter-mandated expansion took effect in 2021. Medicaid has enabled them to get annual checkups, be treated for chronic conditions and undergo long-delayed surgical procedures like joint replacements.
“Once you’re on it, it works beautifully,” McCandless said.
This is the outcome that opponents most feared in the long, bitter expansion debate — that once passed, Medicaid expansion would be impossible to get rid of.
Turns out, they may be right. Even an act of Congress may not be enough to shut it down.
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