(CN) — The Missouri Supreme Court ruled unanimously Thursday that the state must implement a 2020 voter initiative that required it to expand Medicaid health care coverage for low-income residents.
The Missouri General Assembly had previously approved funding for only limited categories of Missouri residents, but the ballot initiative approved by Missouri voters in August 2020 amended the state constitution to require the state to cover a new category of eligible Missouri residents, including adults aged 19 to 64 whose income is at or below 138% of the federal poverty level. This would cover an estimated 275,000 additional residents.
Because the Missouri Legislature failed to appropriate sufficient funds for the Medicaid expansion, the state did not implement the expansion in March, as required in the constitutional amendment.
Three Missouri residents who would be eligible for Medicaid coverage under the expansion sued state officials, challenging the refusal by the Department of Social Services to provide expanded coverage because of the lack of funding.
Cole County Circuit Judge Jon Beetem struck down the voter-approved Medicaid expansion on June 23, finding the referendum was unconstitutional because it lacked a funding mechanism. The case was immediately appealed to the state’s high court.
On Thursday, the justices, sitting en banc, reversed the trial judge in a 14-page per curiam decision and remanded the case to the lower court to enter a judgment for the plaintiffs, including a determination of appropriate injunctive relief.
The state had argued that the ballot initiative is not enforceable because the Missouri Constitution provides that voter initiatives “shall not be used for the appropriation of money other than of new revenues created and provided for thereby, or for any other purpose prohibited by this constitution.”
Missouri State Solicitor General John Sauer told the Supreme Court justices at a July 13 oral argument that the Missouri Constitution, which states that the people, by initiative, may only spend or appropriate the revenues that they raise in the initiative, is central to the case.
Sauer told the court that there was no ambiguity in the Medicaid appropriations bills approved by the legislature that the funding was provided for preexisting Medicaid recipients only.
The justices, however, said the constitution prohibits only initiatives used for the “appropriation of money,” including an initiative that “deprives the General Assembly of discretion and requires it to appropriate money for the initiative’s purposes.”
An initiative “that simply costs money to implement does not necessarily require the appropriation of funds so long as the General Assembly maintains discretion in appropriating funds to implement that initiative,” the court said.
While it is possible the Missouri Legislature appropriated less money than the state’s Medicaid program will need in the coming fiscal year, the court said the consequence of the state’s failure to fully fund the program is not before the court and is not relevant to the question of whether the initiative violates the constitution.
A spokesman for the Missouri Attorney General’s Office declined to comment on the decision.
The plaintiffs' attorney, Charles W. Hatfield of the Stinson law firm in Jefferson City, could not be reached for comment Thursday afternoon.
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