JEFFERSON CITY, Mo. — Republican lawmakers are again seeking to restrict the Medicaid expansion voters approved in 2020, proposing work requirements for the estimated 275,000 low-income Missourians newly eligible for the health care program.

A constitutional amendment filed in the General Assembly this week by House Budget Chair Cody Smith would make funding for that group of recipients subject to annual review, separating them from overall support for the traditional Medicaid program.

It is the latest attempt by Missouri Republicans to curb the expansion of the program to working adults without children after defeats at the ballot box and in court.

Voters approved a constitutional amendment expanding Medicaid with 53% of the vote in August 2020, after years of refusals by the Legislature.

Most states have expanded eligibility through a provision of the Affordable Care Act, which allows those earning up to 138% of the federal poverty level to receive Medicaid. In 2021, that was just under $17,800 for a single adult and $36,570 for a family of four. Previously, Missouri allowed few nondisabled adults onto the program; parents were eligible only if they made about $5,830 for a family of four.

Republicans refused to put money in the budget last year for the new recipients. It led Gov. Mike Parson to halt expansion until the state Supreme Court unanimously ruled the state must allow eligible Missourians to enroll. Parson's administration last year estimated expansion would cost $130 million in state funds and come with $1.6 billion from the federal government.

By expanding, the state also receives about $1 billion in incentive funds from the Biden administration, as part of the American Rescue Plan.

As of last week, 53,151 have enrolled in the expanded program since October. The Department of Social Services has about 69,000 applications pending, officials told the House Budget Committee on Monday.

Under the court order, the state is required to enroll new recipients regardless of the funding lawmakers approve for Missouri's Medicaid program, known as MO HealthNet. Without additional money the entire program has only enough cash to operate through mid-February, budget director Dan Haug said.

The money to make up the difference is included in an emergency supplemental budget bill that also includes pay raises for state workers and allocates federal aid dollars. Funds for expansion would be coming not out of general revenue, but federal COVID-19 relief money that lawmakers set aside previously.

Parson has told lawmakers he wants to have the bill passed by Feb. 1. With two weeks remaining, it has yet to reach the House floor, or the Senate.

Smith has repeatedly raised concerns about the ongoing costs of the expansion, though Missouri currently enjoys record revenues. It is receiving about $2.7 billion in federal funds from the Rescue Plan. The state ended the fiscal year last July with a $1 billion surplus and expects to do the same this year.

Asked last week if he would commit to paying for the expanded program this year and next year, Smith told reporters lawmakers were "in a different landscape than we were in last year" with a court ordering enrollment.

He could not immediately be reached for comment Friday morning on his latest proposal to curb the expansion. The constitutional amendment he filed would bar the "expansion population" from Medicaid if lawmakers don't pay for the program any particular year, without touching other Medicaid recipients.

And it would require enrollees to work, participate in job training or job searching, or obtain an exemption in order to receive Medicaid. Missouri already has work requirements for welfare and food stamps programs.

Work requirements for Medicaid were encouraged by former President Donald Trump's administration, which approved the rules for a dozen states. Biden's administration has now been rescinding those permissions.

A Harvard School of Public Health study of Arkansas' requirements found that in the roughly 10 months the rules were in place before a federal court halted them in 2019, 18,000 recipients lost Medicaid coverage — about a third of those subject to the rules. Researchers found that few understood the rules were in place and that they did not increase employment among recipients.

If passed by lawmakers, Smith's proposal would go to a statewide vote.

Smith last year filed a bill to undo a different voter-approved measure, a proposal to repeal or slow down minimum wage hikes that Missourians approved in 2018.

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