Missouri Supreme Court rules state's Medicaid expansion constitutional, reversing lower court's decision

Missouri’s Supreme Court ruled Thursday that the state’s Medicaid expansion is constitutional, overturning a lower court’s ruling that the expansion wasn’t valid.

The unanimous ruling found that just because the ballot initiative that voters approved in August 2020 did not say how the expansion would be funded does not mean the initiative was unconstitutional. The ruling is a major win for the Biden administration that has sought to expand Medicaid among the dozen holdout states and for Centene, a major government insurer who had threatened to leave the state over leaders’ refusal to fund the expansion.

Missouri Gov. Mike Parsons and the state’s legislature refused to appropriate funding for the expansion earlier this year, triggering a lawsuit from three residents arguing that the state is required to implement the expansion.

However, a circuit court ruled last month that via existing law the legislature had to choose to fund the expansion or strike down its Medicaid program. The ruling also found that the ballot initiative did not specifically create an appropriation of revenue for the expansion and is therefore unconstitutional.

But the Supreme Court found that the ballot initiative does not deprive the legislature of its ability to approve funds for the state’s Medicaid program. But the state’s Medicaid program is bound by the ballot initiative to enroll residents eligible for coverage under the expansion.

The ruling calls for the circuit court to determine the appropriate relief for the plaintiffs.

The state’s Department of Social Services pulled a request to the Biden administration to approve the expansion after the legislature refused to appropriate expansion funding.

The Biden administration has tried to get the 12 remaining holdout states to expand Medicaid under the law. The American Rescue Plan Act included a five percent boost to the federal matching rate for Medicaid for any of the holdouts but so far none have been swayed.

Ballot initiatives have been used to get coverage in several other red states, although initiatives have gotten pushback from legislatures in terms of funding.