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JEFFERSON CITY — The long Republican-led effort to block the Affordable Care Act in Missouri appears to be coming to a close after the state’s highest court ruled a voter-approved plan to expand Medicaid was valid.

For many observers, the fight is over, and the day when 275,000 low-income Missourians can begin receiving health insurance benefits is on the horizon.

James Layton, who spent two decades in the Missouri Attorney General’s office, put it bluntly when asked if there are any additional legal routes opponents can take.

“Not that I know of,” said Layton, who filed briefs on behalf of clients who would benefit from the expansion. “I don’t see any route.”

But Thursday’s landmark ruling by the Missouri Supreme Court did not address how the state should pay for adding people to the state’s Medicaid program, known as MO HealthNet.

For now, that question is in limbo as officials work through the meaning of the decision and the likelihood that thousands of people will begin being signed up for health insurance later this summer.

In the aftermath, Gov. Mike Parson signaled he may call lawmakers back to the Capitol to again debate whether to add money to the budget to pay for the expansion.

House Budget Committee chairman Cody Smith, a Carthage Republican who led the charge to reject funding the expansion this spring, also is mulling a response in light of the court's unanimous decision.

But, under a series of scenarios discussed during the legislative session, most agreed there is likely enough money in the budget to cover the cost of new enrollees at least through the end of the calendar year.

Then, when lawmakers return to action in January, they can take up discussions on what is known as a “supplemental budget,” which plugs holes in the budget until the end of the fiscal year on June 30, 2022.

A supplemental budget is commonly used specifically to buttress the state’s Medicaid budget, primarily because it is difficult to forecast how much health care recipients will need in a given year.

In fact, much of this year’s $2.1 billion supplemental budget was taken up by adjustments to the state’s Medicaid program that lawmakers hadn’t earmarked in the original spending blueprint approved last year.

Financial details aside, the court’s unanimous decision was met with derision by Republican lawmakers and joy by Democrats.

House Minority Leader Crystal Quade, D-Springfield, said the ruling was “a complete vindication for those who have worked to expand health care access and a thorough rejection of those willing to defy Missouri voters and ignore the rule of law to stop it from happening.”

Like others, Quade said she believes Republicans have run out of ways to block the expansion.

“We expect the trial judge will follow the Supreme Court’s clear direction and promptly order the state to begin providing Medicaid services to the expanded population as mandated by the Missouri Constitution,” Quade said.

Sen. Steve Roberts, D-St. Louis, said the court decision upheld the will of the voters.

“This latest court decision sends a clear message that, throughout this entire process, the only act that was unconstitutional was the effort to undermine the voices of Missouri citizens,” Roberts said.

The people speak

The legal wrangling followed an election last August, in which 53% of the state’s voters decided that the MO HealthNet program should cover adults between the ages of 19 and 65 with incomes below 138% of the poverty level.

That means medical providers would get the ability to begin enrolling people earning under $18,000 per year.

Prior to the ruling, no adult without children was eligible for Medicaid unless they were disabled. Adults with children were eligible if their household income was less than about 16% of the federal poverty guideline.

In all, Medicaid in Missouri costs about $12 billion a year, but much of that cost is paid by the federal government.

The cost of expanding the program is estimated to be $1.9 billion, though all but about $130 million of that would be paid by the federal government. And, the state is not hurting for cash after ending the fiscal year in June with more than $1 billion in reserves.

Currently, Missouri taxpayers cover about 35% of the costs for the traditional Medicaid system. Under the terms of the Affordable Care Act, signed into law by President Barack Obama in 2010, states pay just 10% of the cost of expansion.

In addition, under the separate American Rescue Plan Act, passed this year, Missouri is in line to get an additional $1.1 billion as an incentive for Medicaid expansion.

U.S. Rep. Cori Bush, a Democrat representing St. Louis, said Republicans lied about the state not being able to afford the added enrollees.

“The unanimous Missouri Supreme Court decision to defend the voice of the people is a clear rejection of state Republicans’ attempts to dismantle our democracy and undermine public health,” Bush said.

The court decision marked what could be an end to a long-running saga.

In 2012, former Gov. Jay Nixon, a Democrat, launched a statewide tour to announce he would include Medicaid expansion in his proposed budget because estimates showed it could create 24,000 jobs.

The GOP-led House and Senate didn’t bite.

In 2014, Republican legislative leaders again said it was a nonstarter, pointing to election results that produced a historic Republican supermajority in the state Legislature.

By 2020, frustration with inaction from Republicans boiled over.

In May last year, supporters of the proposed constitutional amendment turned in nearly 350,000 initiative petition signatures to place the proposal on the statewide ballot.

But even that didn’t stop the GOP from trying to block the expansion.

No money

After the success of the 2020 ballot initiative, Republicans took one last stand against funding the expansion. Led by Smith, they said the referendum failed to outline how the expansion would be paid for, a violation of the constitution.

On successive votes in the House, the GOP-majority chamber voted for a state budget without the added money.

From there it was off to court.

The lawsuit filed by Missouri residents Autumn Stultz, Melinda Hille and Stephanie Doyle asked the court to make it clear that they could sign up for benefits beginning July 1, regardless if there is funding for the expansion.

Doyle, of St. Louis, is a single mother of three children who earns $12 an hour working full time. The lawsuit says she struggles with severe eczema and needs two medications for the ailment “but is unable to afford them without health coverage.”

Hille, of Fenton, is unable to work because of medical conditions and earns less than 100% of the federal poverty level, the lawsuit says.

She has Type 1 diabetes, thyroid disease, pernicious anemia and a precancerous colon growth, the lawsuit says.

The third plaintiff, Autumn Stultz, of Springfield, is a single mother working full time at a minimum-wage job, the lawsuit says.

Business groups, including those typically aligned with Republicans, and health care organizations joined the legal fight, filing briefs in support of expansion.

In June, however, Cole County Circuit Judge Jon Beetem sided with the Republicans, saying the referendum was unconstitutional because it failed to include a funding source.

On Thursday, the high court said the Legislature still has discretion over the budget, but the expansion is in the constitution and must move forward.

Jason Hall, CEO of Greater St. Louis Inc., praised the court ruling.

“Medicaid expansion is a pro-growth public policy that supports better health outcomes, creates jobs and promotes racial equity. It is hard to overstate the positive impact this decision will have on economic growth across the state of Missouri,” Hall said.

Health care organizations also applauded the decision.

“For far too long, we’ve seen the devastating impact on patients — disproportionately women, people of color, and people in rural communities — when they fall into the Medicaid gap. Many delay care or cannot access it altogether,” said Yamelsie Rodriguez, president of Planned Parenthood of the St. Louis Region and Southwest Missouri.

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