What's Next? Missouri's Medicaid Expansion after Doyle v. Tidball.

AuthorSimsheuser, Jayke
  1. INTRODUCTION

    For Autumn Stultza, a single mother suffering from severe tonsil stones, Melinda Hille, a Type 1 Diabetic forced to choose between eating and paying for medication, Stephanie Doyle, a mother of three unable to afford her eczema medications, and approximately 275,000 other Missourians, August 10, 2021 was a good day. (1) More than a decade after the enactment of the Affordable Care Act and just over a year since Missourians voted to expand Medicaid, Missourians ages 19 to 65 making under 138% of the federal poverty level became officially eligible for Medicaid coverage through the state's MO HealthNet program. (2) Their excitement, however, may be short-lived.

    In Doyle v. Tidball, the Supreme Court of Missouri held that Medicaid expansion, codified in Article IV, Section 36(c) of the Missouri Constitution, was validly enacted. (3) But, it did so walking a thin and potentially unstable constitutional line. (4) Because the court declined to fully clarify the extent of the General Assembly's discretion in funding the program, (5) it has left the door open to an underfunded MO HealthNet system and future constitutional challenges.

    Part II of this Note outlines the facts and holding of Doyle. Part III explains the history of Medicaid and Missouri constitutional challenges under Article III, Section 51. Part IV then examines the Supreme Court of Missouri's reasoning in deciding Doyle. Finally, Part V argues the court's holding did not go far enough and may result in eligible Missourians being denied the very coverage now guaranteed to them in Article IV, Section 36(c).

  2. FACTS AND HOLDING

    Missouri has long embraced the initiative process, which allows voters to amend the state constitution directly. (6) This process has remained popular and resulted in the passage of a myriad of large-scale policy proposals, including demands for increased minimum wage, sanctioning medical marijuana, campaign financing reform, and more. (7)

    In August 2020, by a vote of 53.25% to 46.75%, Missouri voters amended the Missouri Constitution to expand Medicaid. (8) Before this expansion, Missouri restricted MO HealthNet coverage to certain categories of low-income individuals, including "those receiving state supplement payments for the aged, blind, and disabled; pregnant women; children under age 19; their custodial parents; and those who [were] 65 and older." (9) After nearly a decade of failed attempts, (10) MO HealthNet eligibility drastically expanded to include individuals between ages 19 and 65 with household incomes up to 138% of the federal poverty level. (11)

    In addition to covering 275,000 more Missourians, (12) Article IV, Section 36(c) declares qualifying Missourians "shall be eligible for medical assistance under MO HealthNet and shall receive coverage for the health services package." (13) The amendment also required the Department of Social Services ("DSS") to "submit all state plan amendments necessary to implement this section to the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services" by March 1, 2021, and to "take all actions necessary to maximize federal financial participation in funding medical assistance pursuant to this section." (14)

    Despite the mandate, members of the Missouri legislature intensely debated and resisted funding the program. (15) Notwithstanding a significant budget surplus estimated at $1.1 billion, many Republican members contended that the state could not handle the long-term financial impacts of Medicaid expansion. (16) Even amid a groundswell of support and claims that expansion could actually spur a boon to the Missouri economy, (17) some Republicans argued that their constituents were misled as to the financial effects of Medicaid expansion and vowed to "protect them from that lie." (18) Despite legislative resistance, a plan was submitted in compliance with the Section 36(c) mandate. (19) However, that plan was eventually withdrawn by DSS, citing a lack of adequate funding from the General Assembly. (20) DSS announced it could not provide coverage to the newly eligible population because the General Assembly failed to appropriate funds specifically for those individuals. (21) According to DSS, House Bills 10 and 11 - the appropriation bills funding MO HealthNet Fiscal Year 2022 - "implicitly . . . require[d] that none of the appropriated funds be used to provide coverage or services to individuals who would be eligible for MO HealthNet only pursuant to article IV, section 36(c)." (22) DSS contended that the General Assembly, relying in part on the United States Supreme Court's line-drawing between pre-expansion and post-expansion Medicaid, (23) intended to fund only the pre-expansion population. (24) In light of DSS's interpretation and the General Assembly's apparent intent, Missouri Governor Michael L. Parson withdrew the expansion plan, noting that "[w]ithout a revenue source of funding authority from the General Assembly, we are unable to proceed with the expansion at this time. . . ." (25)

    Plaintiffs Autumn Stultz, Melinda Hille, and Stephanie Doyle, each newly eligible for Medicaid under expansion, filed suit against DSS after it announced its intent not to proceed with expansion. (26) They claimed they were eligible for and entitled to coverage through MO HealthNet and sought: "(1) a declaratory judgment stating DSS' decision to refuse to extend benefits violate[d] article IV, section 36(c); and (2) an injunction requiring DSS and MO HealthNet to take the steps necessary to implement article IV, section 36(c), which include[d] re-filing the state plan amendment." (27)

    The circuit court focused its analysis on whether Article IV, Section 36(c) violated another provision of the Missouri Constitution, (28) Article III, Section 51, which explicitly prohibits initiatives that appropriate funds not raised by the initiative itself. (29) Effectively, this provision prohibits Missouri voters from passing initiatives that are not self-funding or that remove the General Assembly's discretion to use its appropriations power. (30)

    The circuit court found that Article IV, Section 36(c) created a new class of 275,000 eligible Missourians, an obligation on Missouri to cover at least 10% of the cost of the new population's benefits, and an estimated $1.8 million in expansion costs. (31) However, the court also found that Article IV, Section 36(c) did not create its own source of funding. (32) Rather, the court reasoned that Article IV, Section 36(c) implicitly required the General Assembly to appropriate additional funds for Medicaid expansion. (33) Thus, the court "determined the initiative that resulted in article IV, section 36(c) violated article III, section 51 of the Missouri Constitution and, therefore, was never effective." (34) Because of Article IV, Section 36(c)'s "shall be eligible. . . and shall receive" language, the court found that the General Assembly would have no choice but to maintain a Medicaid program and fund its expansion. (35) As such, the circuit court held in favor of the defendants on all claims. (36)

    After some confusion on where to file, (37) plaintiffs appealed directly to the Supreme Court of Missouri, which exercised exclusive appellate jurisdiction under Article V, Section 3 of the Missouri Constitution. (38) Concluding that nothing in Article IV, Section 36(c) deprived the General Assembly of its appropriation discretion, the court held that the amendment did not violate Article III, Section 51 and was, therefore, effective. (39)

  3. LEGAL BACKGROUND

    Medicaid maintains a fickle position in American healthcare and politics. On one hand, Medicaid is the primary vehicle to healthcare for over 75 million Americans. (40) On the other, the program - and particularly its expansion - remains a source of sharp criticism from Republican and right-wing politicians. (41) As states like Missouri have sought to extend the program after the passage of the Affordable Care Act, they have been met with a frenzy of political and legal attacks. (42) To better understand the development of Medicaid in Missouri and the legal challenges to its expansion under Article IV, Section 36(c), this Part examines the history of both MO HealthNet and challenges to it under Article III, Section 51. Specifically, this Part first discusses the history of Medicaid, subsequent legislative acts affecting the program, and the program's current impact in Missouri. Next, it examines the history of Article III, Section 51 challenges in Missouri and the Supreme Court of Missouri's approach to citizen-led initiatives.

    1. Medicaid and Subsequent Legislative Acts

      Since its enactment under Title XIX of the Social Security Act, (43) Medicaid has become a central facet of American healthcare. (44) The public insurance program gives federal funding to states that provide medical insurance for some of its neediest populations. (45) Although state participation is voluntary, every state in the country has elected to participate since 1982. (46) Missouri was quick to adopt the program and has continuously participated since 1967. (47) With 75 million Americans, including one in every six Missourians (before Article IV, Section 36(c)), receiving benefits under Medicaid through state programs, Medicaid's importance is difficult to overstate. (48)

      The program is jointly funded by federal and state governments but is run largely at the direction of the states. (49) As long as a state's Medicaid program meets the minimum federal standards, it receives federal funding as determined by the Federal Medical Assistance Percentage ("FMAP"). (50) Generally speaking, a state's wealth relative to the rest of the country determines its FMAP apportionment. (51) FMAPs range between 50% and 83%, (52) with Missouri at 66.36%. (53)

      While Medicaid coverage was originally limited to "pregnant women, children, needy families, the blind, the elderly, and the disabled,"...

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