After years of stalling at the Capitol, plans to expand Medicaid in Missouri appear headed to the ballot this fall.
But when voters make their decision, a leading state legislator wants them to consider making some beneficiaries work for their coverage, too.
A resolution from Rep. Cody Smith, R-Carthage, would require “able-bodied” beneficiaries ages 19-64 to work, attend school, search for a job or volunteer for at least 80 hours a month to stay on the rolls.
The idea, he told a House committee Tuesday, is “to contain or be able to manage the budgetary challenge of Medicaid expansion,” which Republicans have been warning about for years amid calls for change.
Smith noted that his resolution exempts people in a number of situations, including those caring for young children or dealing with a family emergency, such as a divorce or domestic violence.
Under current regulations, state analysts predict the change would lead to the removal of just 2,282 people with very low incomes out of hundreds of thousands of others on the rolls.
But if voters approve plans to expand the program this fall, individuals making up to about $17,600 per year and families of three making about $30,000 per year could qualify, and Smith said that’s what he’s looking at.
“That would be some 250,000 (newly eligible) individuals, perhaps more, that would be a population that would largely be affected by this,” he said.
Democrats, who generally see work requirements as barriers designed to make it harder for people to get help even if they’re eligible, objected to the idea.
Rep. Deb Lavender, D-Kirkwood, said recent history suggested people could lose coverage even if they fulfill work requirements.
She pointed out that issues with paperwork and processing led to tens of thousands of children being removed from Medicaid rolls in the last two years even though they were likely eligible for benefits.
“Where I would state that perhaps procedurally we’ve prevented people from having access to health care, I would have the same concern here,” she said.
Rep. Tommie Pierson, D-St. Louis, had similar thoughts.
“It just seems like we are creating an additional burden on folks that may legitimately need access to health care,” he said. “And if they already have some challenges, I want to be clear … that we are making it harder for folks who are in need.”
Smith said enrollment issues should be considered separately, though.
"It's not my intention to make enrollment more difficult," he said. "I think that's kind of an issue aside, in a vacuum."
Rep. Barbara Washington, D-Kansas City, also worried that a plan to save money might actually cost more in legal bills given recent federal court decisions knocking down similar plans in Arkansas and Kentucky.
Judges in both cases ruled that those states’ programs were invalid because the federal law that created Medicaid intended it to provide health care to low-income Americans, not encourage people to get jobs.
Smith said it wasn’t his intention to draw a lawsuit, but acknowledged the potential for one.
A number of outside groups also objected to the idea philosophically and practically.
The left-leaning Missouri Budget Project estimated a proposal similar to Smith’s could cost the state more than $215 million per year by creating the need for more bureaucracy to process the changes.
A report from researchers at Washington University in St. Louis suggested expansion alone could save the state $932 million by 2024 and drive down costs by helping patients address problems before they become expensive emergencies.
Another report released earlier this year by groups representing Missouri physicians, nurses and hospitals indicated costs could be offset by careful planning, too.
The official state analysis from Democratic State Auditor Nicole Galloway's office says the state government can expect an impact ranging from at least $200 million in increased costs to savings of $1 billion by 2026.
Smith’s resolution would also ask voters to make several other additions to the state’s constitution.
Two would codify popular provisions from the federal Affordable Care Act barring health insurance companies from denying coverage for pre-existing conditions and allowing dependent children to stay on their parents’ health insurance until they’re 26 years old.
Another change allowing the legislature to end payments to hospitals for treating out-of-state patients may prove less popular, though.
Rep. Brenda Shields, R-St. Joseph, and Rep. Allen Andrews, R-Grant City, both pointed out that those payments provide vital support to children’s hospitals in Kansas City and St. Louis that serve wider regions and worried about the impact there.
A vote on the resolution is scheduled for Wednesday.
The legislation isHouse Joint Resolution 106.