Days after it was announced that Medicaid expansion could be on November’s statewide ballot, Missouri lawmakers discussed additional requirements that could limit coverage.

The Missouri Budget Committee heard testimony Tuesday in regard to House Joint Resolution 106. The resolution would require some working-age adults who receive Medicaid benefits to complete work requirements or risk losing coverage. It also would halt Medicaid payments for hospital services provided to non-Missouri residents.

If passed by legislators, the measure would be placed on the state ballot in November, likely alongside Medicaid expansion. Just last Friday, supporters of expansion turned in nearly twice as many petition signatures needed for it to be presented to voters. Election officials are checking the signatures.

With only a week and a half left in the legislative session, Republicans have proposed HJR 106, sponsored by Budget Committee Chairman Cody Smith, R-Carthage. It would amend Missouri’s constitution to require “able-bodied” Medicaid recipients aged 19-64 to work at least 80 hours a month.

This could include a combination of employment, education, job search, child care and other volunteer services. However, the resolution outlines several groups that could receive exceptions because they may not be able to complete the requirement, including those who are:

Medically frail and have certain physical or mental disabilities. Pregnant or caring for a child less than a year old. The primary caregiver for a dependent child or adult. Participating in federal welfare or food stamp programs and already exempt from work requirements of those programs.

The resolution also exempts those facing specific burdensome situations including the death of a family member, divorce and natural disasters.

Rep. Dirk Deaton, R-Noel, commended the list of exceptions: “It would give the department even further discretion, again, to make sure you’re not harming those who are in a vulnerable situation, who would need to access this and who have experienced something through no fault of their own.”

Deaton also said he believed these work requirements could move people from welfare into work, increase incomes and give greater independence to families.

Some lawmakers and organizations, however, are concerned that the resolution would cause many people to lose their coverage due to added administrative burdens and inefficient processes. Rep. Deb Lavender, D-Kirkwood, said she believed thousands of children were dropped from Medicaid last year because of issues with paperwork, computers and call centers. She expressed the same concerns with HJR 106.

In a statement, Jen Bersdale, executive director of Missouri Health Care for All, echoed that concern. “Under the Parson administration, Missouri has purged more than 100,000 eligible children from Medicaid over the last two years due to bureaucratic error,” she said. “Why would we even consider adding additional red tape?”

Other states, such as Arkansas and Kentucky, have implemented similar work requirements to Medicaid programs but have received criticism and even lawsuits.

With the timing of the resolution coming so soon after the state received the signatures for Medicaid expansion, some lawmakers questioned how the House proposal would affect the proposed expansion, which would extend eligibility to adults with earnings up to 138% of the federal poverty level.

Smith said that if both proposals passed, his resolution could require the newly eligible adults to meet work requirements and would keep legislators in control of the program’s purse strings.

“I think that it’s important that people understand that,” responded Rep. Ingrid Burnett, D-Kansas City. “That should they vote for this language, this language would possibly undo language that they would vote for in the other initiative.”

While Smith said he did not propose the resolution because of Medicaid expansion, he agreed that the it would almost exclusively apply to those who would receive benefits if the program expands.

The fiscal note of the resolution asserts that as many as 13,433 people could be affected by the work requirement, but this number would greatly increase if voters approved Medicaid expansion.

“It just seems like we are now creating additional burden on folks who may legitimately need access to health care,” said Rep. Tommie Pierson Jr., D-St. Louis County. “I just want us to be clear that we aren’t really making it easier for folks; we are making it harder for folks who arein need.”

Another aspect of HJR 106 would allow Medicaid to reimburse providers only for services to Missouri residents. Currently, Medicaid uses a voluntary tax paid by hospitals to pay for patients from other states. In return, hospitals receive federal money that is used to fund treatment.

Rep. Brenda Shields, R-St. Joseph, pointed out that many of the hospitals that use this federal money are children’s hospitals that offer specialized care to those who cannot find treatment in their home states. Without this tax, hospitals such as Cardinal Glennon in St. Louis and Children’s Mercy in Kansas City would see an acute loss in funding.

“Children’s hospitals are regional for a purpose. They are incredibly expensive to operate,” Shields said. “Blood pressure cuffs go around something as small as your finger. You don’t find those in all other hospitals.”

Recognizing the financial loss to certain institutions, Smith said he would introduce an amendment soon that would delay the implementation by a few years. He said he hoped a waiting period would give hospitals a transition period.

Discussion of the measure resumes Wednesday, when the committee could vote on whether to send it to the full House. The legislative session ends May 15.