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Court smacks down GOP effort to ignore voters' will on Medicaid

Missouri voters approved Medicaid expansion. Missouri Republicans said they didn't care. Missouri's Supreme Court said the GOP doesn't have a choice.


Missouri residents voted last year to bring Medicaid expansion to their state. It wasn't easy, but as the St. Louis Post-Dispatch reported, the state Supreme Court ruled unanimously that state officials cannot ignore voters' will.

Moving with uncharacteristic speed, the high court overruled Cole County Circuit Judge Jon Beetem's decision that upended the long-running push to add as many as 275,000 low-income Missourians to the government-run health insurance program. In doing so, the court called Medicaid expansion "valid," paving the way for the Missouri Department of Social Services to resubmit an application to the federal government outlining its plan to serve the additional enrollees.

To appreciate the significance of the ruling, let's revisit how we arrived at this point.

By any fair measure, Republicans in Missouri had reason to be delighted with the 2020 election cycle. Donald Trump won the state by 15 points; Gov. Mike Parson (R) cruised to a similarly lopsided victory; GOP representatives won six of the state's eight congressional seats; and Republicans continued to dominate in both chambers of the state legislature.

But while Missouri may be earning its reputation as a ruby-red state, the electoral news for Republicans last year wasn't all good. Last summer, during the state's Aug. 4 primaries, a majority of Missouri voters approved Medicaid expansion -- a decision that was poised to extend health security to roughly 275,000 low-income Missourians currently going without.

GOP officials urged voters to reject the ballot measure. A 53% majority of the state's voters ignored the advice and passed it anyway.

And while that appeared to be the end of the fight, Missouri's Republican-led state government decided it would simply ignore the election results and refuse to enact the voter-approved policy.

As Rachel explained on last night's show, the seven justices on the Missouri Supreme Court rejected the GOP's approach, telling state policymakers that honoring the results of the ballot referendum is not optional.

"It is tempting to ask Republican state legislators who disobeyed the will of the people to apologize for their misunderstanding of the law, and the people," the editorial board of the Kansas City Star wrote. "The decision to refuse to allocate funds for Medicaid expansion clearly violated the state constitution, while slapping voters in the face."

The editors added, "It took some time, but the Missouri Supreme Court has said what everyone knew: The voters had a right to require Medicaid expansion, which they exercised. In Missouri, the people still rule -- not lawmakers who think the poor should suffer in silence."

I don't doubt that Republican officials in Missouri were displeased with the ruling. They fought long and hard to ignore election results and deny health security to poor families, those rascally state Supreme Court justices ruined their plan. It must've been quite a bummer.

But it's worth pausing to appreciate just how much the Show Me State is poised to benefit -- and not just because Medicaid expansion is a good deal on its own terms.

As we've discussed, the Democrats' COVID relief package, called the American Rescue Plan, included provisions on Medicaid expansion, designed to entice red-state holdouts to finally do the right thing.

The policy may sound a little complicated, but the offer was straightforward: under the Affordable Care Act, the federal government already covers 90% of the costs of expanding Medicaid. As Vox explained a while back, the Democrats' relief package upped the ante: "[N]ewly expanding states would also receive a 5 percent bump in the federal funding match for their traditional Medicaid programs for two years. Because the traditional Medicaid population is significantly larger than the expansion population, the funding bump is projected to cover a state's 10 percent match for expansion enrollees and then some over those two years."

It led Jon Chait to joke, "Now states taking the Medicaid expansion would have more than 100 percent of the cost covered by Washington. They would literally have to pay for the privilege of denying coverage to their poorest citizens."

Nevertheless, of the 12 holdout states, literally zero took advantage of the federal offer. That is, until now: Missouri Republicans will grudgingly have to join the Medicaid expansion club, which will unlock a windfall.

As Greg Sargent added yesterday, "We're talking about a lot of money here.... According to Kaiser's calculations, Missouri stands to receive around $1 billion in additional federal funds if this goes through. This is in addition to what the Medicaid expansion itself would ordinarily bring in."

Missouri Republicans may have lost their case, but the rest of Missouri was just handed an important victory.