At least three initiative petitions pushing for Medicaid expansion have been authorized by the Missouri Secretary of State's Office for circulation, with petitioners eyeing their placement on the November 2020 ballot for consideration by voters.
Two of those petitions were submitted by Heidi Miller, a physician in St. Louis. They seek an amendment to either Missouri law or the state constitution to adopt Medicaid expansion for individuals ages 19 to 64 with an income level at or below 133% of the federal poverty level, thereby requiring the state to maximize federal financial participation.
"In being truly patient-centered, we need to advocate for patient health coverage, and if the Legislature hasn't fervently prioritized this, then we are pursuing a petition to reflect the priorities of Missourians in this regard," Miller said in an email to the Globe.
State lawmakers from the Joplin area are solidly among those opposed to Medicaid expansion.
The Affordable Care Act of 2010 directed states to expand their Medicaid programs, although a U.S. Supreme Court ruling in 2012 made that optional. To date, 36 states and Washington, D.C., have expanded Medicaid, according to the Kaiser Family Foundation; Missouri is among the 14 states, also including Kansas and Oklahoma, that have not expanded the program.
The Kaiser Family Foundation, a San Francisco-based nonprofit that focuses on health care issues, estimated in 2016 that 199,000 uninsured adults in Missouri would be eligible for Medicaid under an expansion.
A report earlier this year from Washington University's Center for Health Economics and Policy estimates that 458,000 nonelderly Missouri adults would be eligible for expansion, a number that includes 190,000 uninsured adults, 72,400 with private insurance coverage and 195,750 with employer-sponsored insurance coverage.
That report also concluded that a Medicaid expansion in Missouri "is approximately revenue-neutral and could create cost savings."
"Other forms of savings across other departments, as well as increases to general revenue, are likely," the report says. "There are numerous benefits in terms of health outcomes that have been documented in other states, many of which will likely generate economic dividends over time, as investment in a healthy workforce has been shown in other settings to create."
Exploring the 2020 ballot
Miller said Medicaid is "not perfect," but she notes that most of her patients are employed and yet still cannot afford insurance.
"I take care of many working patients — most of them doing physical labor, which takes a toll on their bodies — who can't afford health insurance, whether or not it is provided by their employer," she said. "I see case after case of medical issues interrupting my patient's ability to perform their job duties. ... Because a healthy workforce is good for the economy and humanity, I don't understand why our Legislature has not adopted Medicaid expansion."
Miller isn't the only one pushing to expand Medicaid. Missouri Jobs with Justice, a statewide coalition, is among the groups exploring how to put the issue on the ballot, said Crystal Brigman Mahaney, communications director.
"Jobs with Justice knows that thousands of Missourians are having to make impossible choices between taking care of their health and being able to afford other life priorities, like rent and food," she said in an email to the Globe. "We also know that too many of our rural health care providers have had to make service cuts or close entirely due to our Legislature’s failure to expand Medicaid — a decision that 36 other states have smartly made."
Missouri Health Care for All also is weighing its options, said KJ McDonald, its Southwest Missouri representative.
"We’ve been a part of exploratory conversations about a ballot measure that’s been filed, and we’re looking hard at that possibility," she said in an email to the Globe. "Ballot initiatives have been a successful vehicle for passing Medicaid expansion in other states, so it’s definitely on the table as an option in Missouri."
McDonald said Missouri Health Care for All, a statewide, nonpartisan grassroots organization, has spent the past six years lobbying legislators to expand Medicaid. If a ballot initiative moves forward, McDonald expects to collect signatures in the Joplin area on its behalf, she said.
Miller said multiple petitions have been filed "as part of the exploratory process" of whether to proceed with collecting signatures.
"Medicaid expansion supporters are expected to make a decision on whether to launch a campaign to put health care on the 2020 ballot by the end of the summer," she said.
What critics say
Missouri lawmakers have consistently declined to expand Medicaid in the state.
Sen. Bill White, R-Joplin and an appointee to the Missouri Health Insurance Innovation Task Force created by Gov. Mike Parson, said he would not support the petitions because of questions about what Medicaid expansion would do to the state's budget.
"We have not (expanded Medicaid) in the state, and I do not see us doing it through the Legislature," he said. "There are big concerns with the affordability of Medicaid expansion."
Rep. Cody Smith, R-Carthage and chairman of the House Budget Committee, said he is "gravely concerned" about Medicaid expansion being placed on the ballot for Missouri voters. He said the state already spends about one-third of its $30 billion budget on Medicaid, and he expects an expansion would draw money away from other budgeted priorities, such as K-12 education.
"If we obligate ourselves to spend more money on Medicaid, those dollars have to come from other programs," he said.
Smith also was critical of the initiative petition process being used to "bypass the legislative process" to promote the expansion of Medicaid, which he called a "consequential and complex" policy decision. He was similarly critical of decisions by voters last year to approve an increase to the state's minimum wage and to authorize medical marijuana, both of which came from initiative petitions.
"The initiative petition process, I'm afraid, is being abused in the state," he said. "I think it's not the way our state was designed to deliberate policy."