The Coming Storm

When Missouri voters approved Medicaid expansion in 2020 through a citizen-led initiative, it was a moment of hope for hundreds of thousands of low-income residents. But that hope may soon give way to crisis. With House Republicans in Washington proposing $880 billion in Medicaid cuts to fund a $4.5 trillion tax break for the wealthy, the financial foundation that supports Missouri's Medicaid expansion is now in jeopardy.

Because of Amendment 2, which was passed by popular vote in 2020, Missouri's Constitution now requires a vast expansion of Medicaid. Prior to this expansion, Medicaid traditionally covered children of low-income families, pregnant women, elderly people in nursing homes, and people with disabilities. This was mandated by law already, but the "Medicaid Expansion" passed in 2020 increased that group of people to include adults struggling to stay above the federal poverty level. Although the increase in Medicaid coverage was great news to hundreds of thousands of Missourians who are now covered, it was a financial headache for politicians in Jefferson City. Fortunately, the federal government covered 90% of that expansion at the time, so the impact on Missouri's budget was inconvenient but manageable.

Here’s the problem: if Washington pulls back its funding, it will directly impact Missouri's budget. Here’s how: Missouri's Constitution guarantees additional funding for Medicaid, regardless of federal funding, so if federal funding dries up, Missourians will still be on the hook to fund it.

So the question becomes: what will the Republican supermajority in Jefferson City do if and when the federal government cuts Medicaid?

They're probably not going to raise taxes. Their track record shows a deep resistance to raising taxes, even if it means extending a lifeline to people in dire health in Missouri. Also, they probably won't risk repealing the Medicaid expansion amendment passed by popular vote in 2020 because if that avenue fails, they'll be in worse financial and political shape.

That leaves two likely, dangerous options: cut the non-expansion side of Medicaid, kicking pregnant women, children of poor families, elderly folks, and disabled folks out to the street, or do what Republicans do best: Delay or sabotage payments to health providers. In other words, play games with the healthcare safety net.

Either option would deliver a financial gut-punch to Missouri's hospitals, especially those in rural areas.

Here's why: Many hospitals, especially rural hospitals, rely on timely Medicaid payments to keep their doors open.  When payments are delayed or sabotaged, patients lose coverage, yet hospitals are forced, by law, to deliver care, even if it means doing so without reimbursement. Many rural hospitals already operate on a negative margin, meaning that they're losing money. Being forced to care for patients without financial reimbursement puts additional stress on them and will likely lead to layoffs, service cuts, or even permanent closures.

As I peer into my crystal ball, I see Governor Mike Kehoe calling a special session if these federal cuts to Medicaid go through. Republicans in the Missouri Legislature will be forced to make some difficult choices. Rural Missourians should brace for impact.

What can we do? Calling your state representative or senator may seem clichéd, but it remains essential. Let them know that cutting traditional Medicaid or stalling hospital payments is unacceptable. Talk to your neighbors. Write to your local paper. Pressure local officials. If we wait until hospitals start shutting down, it will be too late.

This crisis is not theoretical. It’s brewing on the horizon. And it’s going to take every ounce of civic pressure to keep the lights on in Missouri's health care system, especially in rural areas.