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Missouri Republicans pushing work requirements to get health care under Medicaid expansion

 Dr. Jon Roberts, who helped found the now-closed Good Samaritan Care Clinic in Mountain View, testifies Tuesday against changes to Medicaid.
Rudi Keller
Missouri Independent
Dr. Jon Roberts, who helped found the now-closed Good Samaritan Care Clinic in Mountain View, testifies Tuesday against changes to Medicaid.

When the Good Samaritan Care Clinic opened in 2006 in Mountain View, only about 5% of the free clinic’s clients were eligible for Medicaid.

When it closed late last year, that number had risen to 70%, Dr. John Roberts, one of the clinic’s founders, told the Missouri Senate Appropriations Committee on Tuesday.

Medicaid expansion means the clients without health insurance served by the clinic now can find paid care, Roberts said, but if it is taken away, they will have nothing.

Roberts testified against a House-passed proposal that would add work requirements for people newly eligible because of Medicaid expansion and make portions of the Medicaid program subject to annual appropriations.

Many of the clinic’s clients, even if they remain eligible, would have trouble with additional paperwork requirements, Roberts said.

“It would be a massive problem,” he said. “We have some who still can’t read and write who came to the clinic.”

Missouri expanded eligibility for Medicaid to people ages 19 to 64 through a 2020 ballot measure after the Republican majority in the legislature fought it for nearly eight years. GOP efforts to prevent expansion extended to refusing to put the necessary funds in the budget, a move the Missouri Supreme Court overturned in July.

The latest effort, through a proposed constitutional amendment sponsored by Rep. Cody Smith, R-Carthage, would not repeal expansion outright. Instead, it would require clients to work or be in job training at least 80 hours a month or perform 80 hours of community service.

If approved by lawmakers and voters, Smith’s proposal would also make any portion of the Medicaid program not mandated by federal law subject to appropriation. That means people who are receiving services in one fiscal year could lose them in the subsequent year.

Future lawmakers need that flexibility if the state is faced with a choice of cutting Medicaid or funding for schools or public safety, Smith said.

“There has been a little bit of confusion about this legislation,” Smith said. “This does nothing to eliminate the expansion program in Missouri.”

But for Sen. Lincoln Hough, R-Springfield, the proposal is another in a series of measures approved by voters that have been targeted for changes by GOP lawmakers. A law passed in 2010 to regulate dog breeders was weakened substantially in 2011 and a 2018 constitutional amendment to change how legislative districts are drawn was revised by a proposal put on the ballot by lawmakers in 2020.

“I think this legislation is what a large number of people in this state are bothered by people doing year after year,” Hough said.

Since enrollment began Oct. 1, the state has added 76,194 people to the Medicaid rolls, less than one-third the number anticipated before it passed. The budget for all Medicaid services is expected to be $16.7 billion in the coming fiscal year, but the state’s share of paying for the expansion group will be about $200 million, Smith said.

The state is unlikely to be short of cash soon, Smith acknowledged during the hearing. It is sitting on a general revenue surplus of nearly $3 billion. In addition, Missouri will receive $1 billion in federal aid for Medicaid because it expanded eligibility. The extra federal aid should be set aside to pay the state’s share of expansion costs, Smith said, estimating it would provide at least five years of coverage.

“That is my concern,” Smith said. “When it runs out, what happens then?”

The work requirement in the proposal would only take effect if the state received permission to impose it from the Centers for Medicare and Medicaid Services. Two states received permission for work requirements from President Donald Trump’s administration, but President Joe Biden’s administration opposes work requirements for Medicaid.

It would only apply to able-bodied people in the expansion population who do not qualify for an exemption, such as having a dependent child at home or caring for a dependent family member.

The work requirement mirrors the current requirement for people receiving Temporary Assistance for Needy Families, or cash welfare.

To be eligible for Medicaid, a household must have an income below 138% of the federal poverty guideline, or $18,754 per year for a single person and $31,781 for a household of three. That is equal to 32 hours per week at minimum wage, $11.15 an hour, for a single person and full time work at $15.28 an hour for the breadwinner in the household of three.

Sen. Denny Hoskins, R-Warrensburg, said he supports the work requirement.

“It is only the able-bodied adults we are requiring to have some skin in the game…to get free, government health care,” Hoskins said.

Prior to Medicaid expansion, adults with children were eligible for Medicaid if their household income was below the monthly cash welfare benefit, about $282 per month. Adults from 19 to 64 were not eligible unless they qualified because of a disability.

That left many without coverage of any kind because private insurance subsidies under the Affordable Care Act are not available to anyone with an income below the poverty line.

Many clients who came looking for coverage found they fell into that gap between Medicaid and the subsidies, said Patty Hendren, an application counselor and program director at Randolph County Caring Communities.

“It was very devastating to sit behind my desk, knowing that their children qualified but they did not,” Hendren said.

She urged the committee to vote against Smith’s proposal.

“Please, let’s not move backwards,” she said. “Let’s let Missouri move forward.”

This story was originally published on the Missouri Independent.

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