Editor's note: This story originally published in advance of the August primary. It has been edited to include responses from the candidates who will appear on the Nov. 6 ballot.
COLUMBIA — The U.S. Supreme Court's ruling on the Affordable Care Act has left Missouri with a looming decision on expanding its Medicaid program.
The federal health care law originally required states to grow their Medicaid programs or risk losing their existing Medicaid funding from the federal government. States would have been required to take on more patients with higher incomes or risk being unable to fund Medicaid at all.
The Supreme Court, however, rejected this mandatory expansion in its June 28 ruling, which upheld most of the Affordable Care Act. Chief Justice John Roberts said the forced growth of the Medicaid program was a "gun to the head" of the states. The Medicaid provision was the only part of the health-care law rejected by the court.
About 14 percent of the state's population, or 835,000 people have no health insurance. The aim of the Medicaid expansion was to bring that number down.
Because of the Supreme Court's ruling, states will get to choose whether to expand their Medicaid coverage.
States that "opt in" will have to take on all adult residents whose income is 133 percent of the national poverty line. For a four-person household, the 2012 federal poverty line is an annual income of $23,050, which means adults in four-person households with annual incomes of $30,657 would be eligible.
If a state takes this option, the federal government will pay 100 percent of the cost associated with the expanded program for three years. After that, the state will start to gradually pay for the estimated 255,000 new patients.
Missouri's Medicaid program is one of the leanest in the nation, and it is unlikely to grow under Republican leadership in Jefferson City.
Legislative leaders are already calling on the state to reject the federal government's "opt-in" deal. House Budget Committee Chairman Ryan Silvey, R-Kansas City, said he can't see how the General Assembly would think it is a good idea to expand the program. Democratic Gov. Jay Nixon has not yet offered his stance on the issue.
Missouri's current Medicaid program and its history
The federal government created the Medicaid program in 1965 to provide health care to people older than 65, people who are blind or have a disability and families with dependent children. Since then, the program has been expanded to cover pregnant women and children living in poverty, as well as children in state custody.
Missouri's current program covers adults who have children and whose incomes are less than 19 percent of the federal poverty line. The program does not cover adults without children. The federal government pays 63 percent of the costs associated with the current program; Missouri pays the remaining 37 percent.
The program reached its current eligibility levels in 2005, when Republican Gov. Matt Blunt and the Republican-controlled General Assembly cut about 100,000 people off the state Medicaid's program in an effort to balance the state's budget. Before the cuts, adults with incomes less than 75 percent of the federal poverty line were covered by the program.
In 2009, Gov. Jay Nixon tried to reverse at least some of the cuts. Nixon cut a deal with the Missouri Hospital Association to provide health care coverage for 35,000 low-income people at no cost to the state.
Nixon's 2009 proposal would have expanded Medicaid coverage to adult parents with incomes below 50 percent of the federal poverty line. It would have cost roughly $150 million, with the cost split between the federal government and the hospitals.
The Republican-controlled legislature blocked the expansion.
Despite cuts, Missouri's Medicaid spending has been growing. In the 2013 fiscal year, Missouri's Medicaid program will cost $8.2 billion, roughly one-third of the state's $24 billion budget. Of the total cost, $1.7 billion comes from the state's general revenue fund.
How the expanded Medicaid program would work
If Missouri lawmakers choose to grow the state's Medicaid program, the federal government would pay 100 percent of the additional cost for the first three years. Starting in 2017, however, the state would have to start paying only some of the annual costs for the expanded program.
There is no exact estimate of the number of Missourians who would qualify under the expanded Medicaid program. Estimates start at 255,000 people, but some lawmakers acknowledge the number could stretch to 400,000.
The expanded program would also cover adults without children, who are currently left out of Missouri's system.
For the first three years of the program, the federal government would pay an estimated $6 billion over three years at no cost to the state. By 2017, however, the state would have to start contributing to the program's cost.
In 2017, Missouri would pay about $100 million, or 5 percent of the cost annually for the new program. The state's payment would increase by 1 percent every year until 2022. In 2022, Missouri would be paying $247 million, or 10 percent of the program's cost. For all years following 2022, Missouri would continue to pay the 10 percent rate, State Budget Director Linda Luebbering said.
The state could see other cost increases outside of the expansion. About 900,000 Missouri residents are eligible for Medicaid, but not all of them are enrolled. The Affordable Care Act's individual mandate, however, will require them to get insurance, which means many probably will sign up for Medicaid. If they were eligible for the existing state program, then the state must pay the 37 percent matching rate instead of the 10 percent rate offered in the health-care law.
What local candidates would do
Given the timeline for implementing the federal health-care law, it is likely that whoever is elected in 2012 will have to decide whether Missouri should opt in to the expanded Medicaid program. Here's what candidate for local legislative offices had to say about the issue.
State Senate District 19
House District 44
House District 45
House District 46
House District 47
House District 50
Missourian Reporter Matthew Patane contributed to this report.
Supervising editor is Scott Swafford.