Last March marked the 10-year anniversary of the signage of the Patient Protection and Affordable Care Act (PPACA) into law by then-President Barack Obama. Despite the fierce opposition against the law in the early 2010s and more than 70 attempts by the House of Representatives to repeal it, the Affordable Care Act remains the law of the land today.
While the ACA has survived the test of a decade of partisan politics in Congress, its expansion of Medicaid—a healthcare program administered by the states for low income Americans—has yet to be implemented in some states in part due to the Supreme Court’s ruling on the case of National Federation of Independent Business v. Sebelius (2012). In a 5-4 decision along ideological lines, the Supreme Court’s majority opinion—written by conservative Chief Justice John Roberts—stated that the ACA’s expansion of Medicaid must be approved by the governments of each individual state.
Prior to the ACA, the eligibility requirements for Medicaid were limited to families below the poverty line with children or disabilities. This left out many low-income adults who were making too much money to qualify but too little to afford private insurance, as well as those who did not have children or disabilities. With the passage of the ACA, an adult earning up to 138% of the Federal Poverty Line ($17,609 a year) would be able to qualify for Medicaid, but only if they happened to live in a state that accepted Medicaid expansion as stipulated by the Supreme Court. By accepting Medicaid expansion, states would receive funding from the federal government that would cover 90% of the costs, with the remaining 10% to be paid by the states themselves.
As of July 2020, 37 states across the United States have accepted Medicaid expansion, while the 13 other states’ legislatures have blocked it (1). Missouri is one of the states that has yet to expand Medicaid. As a result, there are 350,000 Missourians who have no access to healthcare who would otherwise be covered under the Medicaid expansion. With most legislators in the Missouri State House and Senate being opposed to Medicaid expansion, it is unlikely that legislative action will be taken on the issue. An analysis done by healthcare writer Louise Norris predicts that if Missouri does not expand Medicaid by 2022, it will reject nearly $18 billion in federal funds over 10 years, despite Missourians already paying taxes for it.
Opponents argue that the remaining 10% of the cost for Medicaid expansion (approximately $200 million) that must be put forth by the state is too high of a cost to pay. Republican Missouri Governor Mike Parson and Republican State Representative Cody Smith have argued that the state cannot afford to increase spending, especially during a pandemic when unemployment is high and likely to result in an increase in Medicaid enrollees (2).
On the other hand, proponents of Medicaid expansion estimate that there could be net cost savings for the state. According to a report from health policy researchers Matt Powers, Sharon Silow-Carrol, and Jack Meyer, states that expanded Medicaid, such as Arkansas, Michigan, and Montana, saved millions of dollars in their state budgets. This is due to the fact that the increased coverage of the population provides people with potential chronic illnesses the ability to receive treatments that decrease the likelihood of patients needing costlier treatments in the future such as ER visits and inpatient care. Additionally, the study found that Medicaid expansion would create more jobs and increase personal earnings as access to Medicaid would make job searches easier as well as providing people with more disposable income to pay for other goods rather than healthcare premiums.
Even though the Missouri government may be reluctant to approve Medicaid expansion, the fight to pass it is not a lost cause. A successful petition drive was launched last year to put Medicaid expansion to a referendum, and on August 4th Missourians will have the opportunity to expand Medicaid at the ballot box. This tactic of deciding Medicaid expansion through popular vote isn’t unique to Missouri: Maine, Idaho, Nebraska, Utah and Oklahoma have put Medicaid expansion to a vote despite governors or legislatures of the states opposing it. In all of these referendums, the “Yes” vote to expand Medicaid prevailed. Despite the ACA’s controversiality among the general public as well as members of Congress, the law’s provision of Medicaid expansion is evidently popular, even in strongly Republican states.
While this referendum may be high stakes one, there has yet to be any polling on it. Thus, it will remain unclear if the “Yes” side or the “No” side will prevail until the election returns come in on August 4th. Whether or not Missouri decides to expand Medicaid next month, the debate on healthcare will still remain an important issue in the state and the nation for years to come. With 49% of the country relying on employer-sponsored insurance, the rise in unemployment as caused by COVID-19 is bound to keep healthcare issues on people’s minds for the foreseeable future (3).
Edited by: Daniel Berkovich