On June 23, 2021, a Missouri circuit court ruling put statewide Medicaid expansion under the Affordable Care Act (ACA) in limbo. Although a successful state ballot measure in 2020 ordered the expansion to take effect on July 1, 2021, the legislature ruled out expanded coverage from its fiscal year (FY) 2022 budget and the judge de the circuit court ruled that the state was not required to implement the expansion. This decision, if upheld, has implications for coverage in the state as well as the availability of federal funding to cover the cost.

Figure 1: What is the status of the Medicaid expansion in Missouri?

While the expansion was passed in Missouri through a vote initiative, the governor has since said the state will not expand Medicaid because the legislature did not include the expansion in its budget for. fiscal year 2022 (Figure 1). On August 4, 2020, voters in Missouri approved a ballot measurement which added the Medicaid extension to the state constitution and demanded the implementation of extension coverage by July 1, 2021. The wording of the constitutional amendment prohibits the imposition of charges or additional restrictions on eligibility or enrollment for the expanding population (such as work requirements or bonuses). In early 2021, Republican Gov. Mike Parson included the expansion in his proposed budget for fiscal year 2022 and the state submitted a State Plan Amendment (SPA) to CMS to implement the expansion effective July 1, 2021. In May, however, Governor Parson announced that the Department of Social Services ( State DSS) was withdraw its SPA submission and would not implement the expansion as planned due to a lack of funding: the ballot measure did not include a source of revenue and the Republican-controlled state legislature ruled out the program of his final budget for fiscal year 2022. Although the lawyers subsequently filed a trial in state circuit county court against DSS, in June, a judge ruled that the DSS’s refusal to expand Medicaid is legal because the ballot initiative violated the state constitution by failing to provide a source of funding. The plaintiffs have appealed the decision and the state Supreme Court is due to hear oral arguments in this appeal on July 13.

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Figure 2: Who are the 127,000 uninsured adults in the coverage gap in Missouri?

If the expansion of ACA Medicaid does not continue, the nearly 127,000 uninsured uninsured adults who currently fall into the coverage gap would remain ineligible for coverage (Figure 2). These adults would be eligible if the state expands but currently have incomes above current Missouri Medicaid levels (0% of the Federal Poverty Line (FPL) for adults without children and 21% for parents) but below 100% FPL ($ 12,880 for an individual or $ 21,960 for a family of 3 2021) minimum eligibility for tax credits on the ACA marketplace. National estimates from KFF indicate that nearly 2.2 million adults are in the coverage gap in all non-expanding states (these estimates exclude Missouri because the state had previously planned to implement the expansion. in July). As in other states, most of the people in the coverage gap in Missouri are adults with no dependent children (75%). Although most of the people in Missouri’s coverage gap are white (74%), the gap disproportionately includes people of color compared to those of color. the population of Missouri as a whole (79% White, non-Hispanic). Most (63%) of adults in the coverage gap have at least one full-time (41%) or only part-time (22%) worker in their family. Without the expansion of Medicaid, those in the coverage gap have limited options for affordable health coverage and are likely to face barriers to needed health services.

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Figure 3: What would be the fiscal impact of the expansion of Medicaid in Missouri?

Failure to expand Medicaid in Missouri would lead the state to forgo more than $ 1 billion in additional federal funds available under the American Rescue Plan Act (ARPA) (Figure 3). Governor Parson proposed budget for fiscal year 2022 allocated $ 1.57 billion in total for Medicaid expansion; the federal government would cover the vast majority of that cost, as states would receive a 90% Federal Matching Rate (FMAP) for the expanding population. The Missouri Legislature valued that the state’s expansion costs would be $ 156 million in fiscal 2022, but ultimately chose not to appropriate those funds. The state recently saw increased income and an unprecedented budget surplus. ARPA provides a temporary tax incentive for states to implement the ACA Medicaid expansion by providing for a 5 percentage point increase in the state’s traditional FMAP for two years. This increase would more than offset the increased costs of expanding Missouri: Missouri would receive about $ 1.15 billion in fiscal year 2022 to 2023 due to the ARPA financial incentive. However, the state would ultimately have to cover its 10% share of the cost of expansion over time.

A complete literature review Medicaid expansion studies identify the positive financial impacts of the expansion on state budgets and economies, in addition to improvements in coverage, access, and health outcomes for individuals. With the exception of Missouri, the other 12 non-expanding states are giving up about $ 16.4 billion in additional federal funds available under the ARPA incentive (in addition to the existing 90 percent expansion FMAP). Similar to Missouri, voters in Oklahoma approved a constitutional amendment initiated by the expansion of Medicaid in June 2020; unlike Missouri, however, coverage of the Oklahoma expansion is slated to begin July 1. Because ARPA was enacted before the expansion was implemented, Oklahoma is eligible for the ARPA tax incentive. Enrollment for extension coverage began June 1 in Oklahoma and nearly 100,000 after only a week. While tax issues are part of the math for states that do not expand Medicaid, i.e. the need to cover 10% of costs over time, opposition to ACA continues to be also a factor.

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