The Missouri Senate voted against funding Medicaid expansion Wednesday night, after a debate that will not be the final word on whether 275,000 Missourians become eligible for coverage on July 1.
By a 14-20 vote, with four Republicans breaking ranks with the rest of their party, the Senate rejected an amendment to the Department of Mental Health budget offered by Senate Minority Leader John Rizzo, D-Independence. Soon after, an amendment to the medical services provided through the Department of Social Services was defeated by a similar vote.
The Senate completed work on its $35.1 billion spending plan for the year that begins July 1 after midnight following roughly eight hours of debate. It must be reconciled with the House version, which spent $32 billion, by May 7.
With the action, the Senate aligned its version of the Medicaid budget with the House plan adopted in March on the biggest spending issue of the year. The next move is up to Gov. Mike Parson's administration, which is directed by the state constitution to provide coverage starting July 1.
Parson's office did not respond immediately to an email sent after the vote asking whether it would accept applications and provide coverage absent specific appropriations to implement the section added to the constitution in August.
The debate compressed a decade-long argument into two hours, and every element familiar to long-time observers — moral, economic and social — was aired. But little changed in the familiar alignment, with outnumbered Democrats solidly in favor joined by a small group of Republicans, and the majority of GOP lawmakers opposed.
"You will see hospitals come back to rural Missouri," Rizzo said. "You will see more nurses. You will see more doctors."
Senate Appropriations Committee Chairman Dan Hegeman, R-Cosby, said the cost of the current Medicaid program has increased rapidly in recent years and new obligations would add to the burden.
He acknowledged Missouri is in good financial shape now, with a historic general revenue surplus.
"Nearly everyone in this room is familiar with a time when the state's financial situation is not what it is today," Hegeman said. "My fear about passing expansion is not about what it would do to the state's budget this year, but what implementation of expansion might do in years to come."
The most personal moment came when Sen. Barbara Washington, D-Kansas City, talked about the death of her brother nine days earlier. He returned to the United States from Qatar, where he had insurance, ill with colon cancer, to be at the high school graduation of his twin children.
He was hospitalized a day after his return, she said. He was eligible for Medicare and was waiting to be approved. He was given emergency Medicaid, she said.
"If not for Medicaid, my brother would have died on the street," Washington said.
Prior to the August 2020 vote, accepting the deal offered by the Affordable Care Act for the federal treasury to pay 90 percent of the cost to cover working-age adults was a policy choice.
Now it is a constitutional directive, and at a rally Tuesday, Democrats vowed they would use the courts to order Parson's administration to provide coverage.
The likelihood the courts would do so was enough for Senate Majority Leader Caleb Rowden, R-Columbia. He said he expects the courts to tell the state to provide coverage like it does for every other eligibility category.
Rowden voted for Rizzo's amendment.
"I believe the court can do that," he said. "I believe the court will do that. And when they do, folks in the expansion threshold will be allowed to apply and we will be presented with a very, very large supplemental budget in October, or November, or December."
And some Republicans opposed to expansion made it clear they relish the chance to test the Legislature's power over appropriations in court.
Sen. Bob Onder, R-Lake St. Louis, cited the Constitution's ban on initiatives that appropriate revenue without providing a source of money.
He said he would not "let my decision, my vote, be governed by my fear about what some black-robed tyrant might decide."
The basics of the new eligibility would be coverage for working- age adults who earn up to 138 percent of the federal poverty guideline, or $17,774 a year for a single person. That is equal to working about 33 hours a week at the state minimum wage of $10.30 per hour. For a household of four, the limit is $36,570, the income of one person working full at $17.58 an hour or two people working a combined 68 hours a week at minimum wage.
During the debate, Senate Appropriations Committee Vice Chairman Lincoln Hough, R-Springfield, laid out the economic argument. The state can afford the additional expense because it has a historic general revenue surplus and has banked $500 million from supplemental federal Medicaid support for the COVID-19 pandemic.
In addition, he said Missouri should act to get the $1.2 billion in additional support for its traditional Medicaid program only available if it expands Medicaid eligibility.
"I believe in my heart," Hough said, "it is the right thing to do."
The Missouri Independent is a nonprofit, nonpartisan news organization covering state government and its impact on Missourians.