Attorneys representing three plaintiffs who filed a lawsuit for the right to receive Medicaid benefits argued Monday in Cole County Circuit Court that it is unconstitutional for the state of Missouri to not provide funding for Medicaid expansion. The plaintiffs are eligible for Medicaid coverage under a constitutional amendment approved by voters last August, but the budget for the coming fiscal year, passed last month by state lawmakers and Gov. Mike Parson, did not include enough funding for expansion.
The constitutional amendment that won approval last year is supposed to expand access for the public health care program to include an additional 275,000 Missourians by extending eligibility to adults earning an annual income of up to $17,774 for a single individual.
Medicaid expansion was a key piece of President Barack Obama’s Affordable Care Act, which provided federal matching funds for a percentage of the expenses incurred by states expanding their programs. To date, 38 states and Washington have approved Medicaid expansion, although it has yet to be enacted in Missouri and Oklahoma.
On Monday, attorneys Chuck Hatfield and Lowell Pearson represented the three plaintiffs — Stephanie Doyle, Melinda Hille and Autumn Stulz. Assistant Attorney General John Sauer represented the state. Cole County Circuit Judge Jon Beetem heard the case.
Under Missouri’s voter-approved constitutional amendment, Medicaid eligibility was due to expand on July 1. Beetem is expected to give his decision on the case by Wednesday. However, that ruling is likely to be appealed, regardless of the verdict, and some anticipate the case will reach the Missouri Supreme Court.
Though there is no specific precedent for this case, Hatfield built his arguments on language contained in a case involving Planned Parenthood of Greater St. Louis that reached the Missouri Supreme Court. In that case, Planned Parenthood was to be denied eligibility as an approved Medicaid provider.
However, the Missouri Supreme Court decided that it was impermissible to use an appropriations bill to amend a substantive statute. Hatfield said this reflected what was being done with Medicaid expansion, as it was approved as a constitutional amendment yet the General Assembly attempted to use a lack of funding for the program to invalidate it all.
Hatfield argued that there was no specific mention in the state budget for the upcoming fiscal year that money allotted for Medicaid could not also be used to fund the expansion. This is in contrast to language included in a 2019 bill specifying that no funds were to be used for expansion. This bill is passed annually and pertains to funding for the Department of Social Services, through which Medicaid is funded. This language was removed after the Planned Parenthood case.
“If they are going to fund Medicaid, this (expansion) population must be included,” Hatfield said.
However, Sauer questioned whether the lack of language in the state budget prohibiting Medicaid expansion implied that the program could be funded. Hatfield argued that it did.
“The legislature will say that it does not hide elephants in mouse holes,” Hatfield said. “But that is exactly what is happening here.”
Sauer contested this assumption, pointing out a similarity in the budget language and funding amounts in both fiscal year 2021 and 2022.
It is assumed that “because there wasn’t a clear bells and whistles announcement that Medicaid was not funded, it must be (funded)” Sauer said.
Sauer said that in Cady v. Ashcroft, a 2020 case that resulted in the Medicaid expansion measure being approved for the state ballot, there was a clear distinction between eligibility for benefits and the funding of said benefits.
Initiatives added to the Missouri Constitution cannot be used “for the appropriation of money other than of new revenues created and provided for thereby.” Since the Medicaid amendment was not funded by the General Assembly, it should be considered null and void by default, as it would force the appropriation of funds not initially set aside for expansion, Sauer argued.
Sauer’s case hinges on the pretense that a “reasonable reader” could read the state budget bills pertaining to the Medicaid program and see that there was not a substantially larger amount of funding added for the purpose of expansion.
Beetem questioned the designation of “reasonable,” stating that the reader would have to actively read all of these bills, and have an understanding of the federal matching funds ratio applied to the existing Medicaid program, as well as what would have been applied to Medicaid expansion.
“Where do I get that inference without knowing all of these things?” Beetem said.