On July 22, the Missouri Supreme Court unanimously ruled that a constitutional amendment enacting Medicaid expansion was constitutional. The decision reversed a lower court’s ruling that found the amendment approved by voters last August to be unconstitutional because it did not include a revenue source for the state to pay for the Medicaid expansion. The Supreme Court ruled that the amendment “does not remove the General Assembly’s discretion in appropriating money to MO HealthNet,” and therefore, “the circuit court erred in declaring article IV, section 36(c) constitutionally invalid.”

The Supreme Court concluded that the Department of Social Services and Missouri HealthNet, who are responsible for the administration of Medicaid in Missouri, are required to use the funds appropriated by the legislature on all eligible recipients under the adopted amendment. The amendment, which was approved by a margin of 53.27% to 46.73%, expanded Medicaid eligibility in Missouri to adults that are 19 years of age or older and younger than 65 whose income is 138% of the federal poverty level or below under the Affordable Care Act.

Stephanie Doyle, Melinda Hille, and Autumn Stultz—three individuals who qualify for Medicaid under the expanded eligibility—filed the lawsuit in Cole County Circuit Court. On June 23, Cole County Circuit Judge Jon Beetem ruled that the amendment was unconstitutional because it did not include a way for the state to pay for the Medicaid expansion. He wrote, “If the court allows them to spend other state revenues by initiative such action would deprive the General Assembly of its constitutional right to appropriate revenues in all other non-initiative circumstances.”

Amy Blouin of the Missouri Budget Project said, “As a result of the Supreme Court’s ruling, Missourians across the state will finally be able to realize the health and economic benefits of Medicaid expansion. State after state has shown that in addition to providing insurance to those eligible, expansion is a fiscal and economic boon to state economies and budgets.”

Senate Appropriations Committee Chairman Dan Hegeman (R), who opposed the amendment, said, “The legal gymnastics employed by the court to get their desired political outcome sets a dangerous precedent and greatly diminishes the power of Missourians’ elected representatives.”

Since the Supreme Court has upheld Medicaid expansion, the state must file paperwork with the federal Centers for Medicare and Medicaid Services to set up the enrollment process for newly eligible individuals. Governor Mike Parson (R) previously withdrew the state’s paperwork in May after the state legislature passed the state’s budget without expanding funding for Medicaid.

The amendment faced legal challenges before the vote last August. In May 2020, two separate lawsuits were filed against Missouri Secretary of State Jay Ashcroft (R) challenging the constitutionality of the citizen-initiated ballot measure by Americans for Prosperity-Missouri and United for Missouri. Both lawsuits argued that the initiative was unconstitutional because it appropriated state funds without creating a new source of revenue. In June 2020, Cole County Circuit Judge Daniel Green ruled in favor of the initiative keeping it on the ballot. Judge Green argued that the ballot measure does not require the state legislature to appropriate money for Medicaid expansion, and therefore, it does not need to provide a funding source. Missouri Western District Court of Appeals upheld Judge Green’s decision to keep the initiative on the August ballot after United for Missouri and Americans for Prosperity-Missouri appealed the decision.

Missouri joins 38 states and Washington, D.C., in expanding Medicaid under the Affordable Care Act.