Medicaid Expansion and Missouri: So Much for the Popular Vote

Members of Missouri’s legislature voted to overturn the expansion plan.

What happens when a state votes to pass Medicaid expansion? One would think it mean that Medicaid expansion gets implemented – although not if you live in Missouri.

Let’s back up.

As of April 1, some 39 states, plus the District of Columbia (which tries to be a state) have passed and adopted Medicaid expansion. Twelve states have not adopted expansion, few enough that I can name them quickly: Alabama, Florida, Georgia, Kansas, Mississippi; North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. Now, two states have adopted expansion, but not yet implemented it, and here’s where our plot thickens: those are Oklahoma and Missouri.

Oklahoma voters approved a ballot measure in June 2020, adding Medicaid expansion to the state’s Constitution. Per amendment requirements, the Oklahoma Health Care Authority submitted a state plan amendment to the Centers for Medicare & Medicaid Services (CMS) within the requisite 90 days of the ballot measure’s approval, for expansion coverage to begin no later than July 1. No issues there. However, Missouri is a different story.

Qualifying for Missouri Medicaid was a challenge, but this was all to change in July, just like Oklahoma:

  • Adult eligibility was a challenge, but would be possible;
  • Childless adults were ineligible through the state’s program, but would now be covered if they earned less than $17,700; and
  • Roughly another 275,000 Missourians would have access to coverage.

These are all wins, especially since the gains associated with Medicaid expansion more than outweigh any costs. However, earlier this month, members of Missouri’s legislature voted to overturn the plan, claiming “state spending on expansion is irresponsible” – even though the federal government covers 90 percent of the costs for those covered under expansion. Actually, make that 95 percent of the costs, counting the extra 5 percent for new expansion states from the American Rescue Plan Act recently signed into law by the President. Anyone confused? I am, especially given the merits and savings associated with expansion:

  • Expansion states experienced major coverage gains and reductions in uninsured rates among low-income populations and for those most vulnerable; 
  • Expansion improved patient access to care, utilization of services, affordability of care, and financial security;
  • Pre-COVID, expansion states experienced decreased mortality, to the tune of 19,000 lives saved, and overall improved health and behavioral health outcomes for those persons eligible; and
  • In addition, there was a 55-percent reduction in uncompensated hospital care costs: roughly $17.9 billion, compared to an 18-percent in non-expansion states.

These enhanced clinical and fiscal outcomes, plus that extra 5 percent, are big incentives to now push non-expansion states like Texas to consider changing their stance. The current Medicaid expansion map lives on the Kaiser Family Foundation website.

Our Monitor Mondays Listeners Survey asked those tuning in about their thoughts on Medicaid expansion. The interesting results appear here.

Programming Note:  Listen to Ellen Fink-Samnick’s live reporting of the social determinants of health (SDoH) every Monday during Monitor Mondays, 10 a.m. Eastern.



Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

Ellen Fink-Samnick is an award-winning healthcare industry expert. She is the esteemed author of books, articles, white papers, and knowledge products. A subject matter expert on the Social Determinants of Health, her latest books, The Essential Guide to Interprofessional Ethics for Healthcare Case Management and Social Determinants of Health: Case Management’s Next Frontier (with foreword by Dr. Ronald Hirsch), are published through HCPro. She is a panelist on Monitor Mondays, frequent contributor to Talk Ten Tuesdays, and member of the RACmonitor Editorial Board.

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