As members of Congress mull their options over how to construct a massive immigration, energy and tax cut bill, some conservative federal lawmakers are embracing reducing the contribution to states that expanded Medicaid.
And while it’s not a sure thing that the idea will end up finding enough GOP support to pass, some of Missouri’s budgetary leaders are closely watching Congress since the state’s voters constitutionally protected Medicaid expansion more than four years ago.
Congress is in the process of putting together what’s known as a reconciliation bill, which is a measure that could pass through Congress without requiring 60 votes in the Senate. With conservative members of the House demanding spending cuts, Politico reported last month that one idea to cut the cost of the final package is reducing the federal contribution to state Medicaid expansion programs.
Missouri voters passed a constitutional amendment expanding Medicaid in 2020 to 138% of the federal poverty level, which is about $26,650 a year for a family of three. The federal government currently pays for 90% of the roughly $3 billion cost to cover about 325,000 participants in the program.
Dave Dillon of the Missouri Hospital Association said there’s nothing in the amendment that would allow the Department of Social Services to stop taking in Medicaid expansion applicants if the federal government reduces its share toward funding the program.
And because Medicaid expansion is in the state constitution, Missouri lawmakers can’t reduce eligibility to the program. Instead, voters would have to approve another ballot item repealing the Medicaid expansion amendment, which passed in 2020 with 53% of the vote.
Missouri’s budget could take a massive hit if Congress ends the 90% match to Medicaid expansion states, said Senate Appropriations Committee Chairman Lincoln Hough.
The Springfield Republican estimated that if the federal share to pay for Medicaid expansion went down to 60%, the state would need to find around $750 million in general revenue to fill in the gap.
“This pits the long-term future of the state against the immediate needs of paying for health care that’s constitutionally, in my opinion, protected,” Hough said. “Every percent of that reduction that’s made to that population is going to cost this state in general revenue somewhere between 25 and 30 million. And that is real money, and it adds up very quickly.”
Onder accuses Republicans of cowering over Medicaid
The House is slated to vote this week on a budget resolution paving the way for a reconciliation bill later in the year.
None of the federal lawmakers whom St. Louis Public Radio contacted explicitly endorsed reducing the Medicaid expansion federal match. But at least two members of Missouri’s House delegation recently blamed Medicaid expansion for the program’s struggles.
In a Facebook post, U.S. Rep. Bob Onder criticized Republicans who “cowered” over Democrats lambasting them for “cutting Medicaid.”
“This is unsustainable,” Onder, R-St. Charles County, wrote. “If Medicaid is to be preserved for the truly needy, it must be reformed, including initiation of work requirements. And the 2025 reconciliation bill is a great place to do it!”
In an interview with conservative radio host Todd Starnes, U.S. Rep. Eric Burlison, R-Greene County, cited Medicaid expansion under the Affordable Care Act as one of the main reasons the program has become unsustainable.
“These are able-bodied young adults that Obama tripled the population into so that he could try to basically back door a single-payer system,” Burlison told Starnes.
Other Missouri lawmakers are taking a wait-and-see approach.
“Simple changes like strengthening requirements for work in Medicaid can help the program save billions for those in need,” U.S. Rep. Jason Smith, R-Salem, said in a statement. “In my conversations with the president, he has made it crystal clear that he is committed to defending Social Security, Medicare and Medicaid. I’ll continue working with President Donald Trump and my colleagues in Congress to deliver one big, beautiful bill that will lower taxes for the working class, end the border crisis, cut wasteful spending, and unleash American energy.”
Arthur Bryant, a spokesman for U.S. Rep. Ann Wagner, said the Ballwin Republican will be monitoring what comes out of the House Energy and Commerce Committee in terms of changes to Medicaid. No one from Missouri’s House delegation serves on that committee.
“We will have to see what proposals come forward as this process continues,” Bryant said. “And if there are effects on Missouri taxpayers, we will be sure to weigh those as we would any legislation that comes to the House floor for a vote.”
Challenges in Congress
Some lawmakers aren’t sure there’s enough GOP support to significantly cut the federal contribution to state Medicaid expansion programs.
Republicans have an extremely narrow margin in the U.S. House — and will likely need near-unanimous support to get a reconciliation package through. Republicans from Medicaid expansion states, especially Democratic-leaning ones like New York or California, may be hesitant to agree to end or reduce the 90% match.
“I think that there's certain things that should not be politicized,” said U.S. Rep. Wesley Bell, D-St. Louis County, in an interview with St. Louis Public Radio. “And when we're talking about access to quality and just basic health care, I think that's something that shouldn't be a Democrat or Republican issue. We should all be fighting and dying on that hill.”
The other roadblock could be in the Senate, where Republicans have openly spoken out against cuts to Medicaid. That includes Missouri U.S. Sen. Josh Hawley, who told reporters last week that he’d be “really concerned about deep Medicaid cuts” in a reconciliation bill.
“If you're going to talk about people who are working and otherwise qualify, if we're talking about significant benefit cuts, I'd be really concerned about that,” Hawley said.
Hawley ended up voting for a number of unsuccessful Democratic amendments to the GOP budget plan. That included one from Senate Minority Leader Chuck Schumer, D-New York, that would block consideration of tax cuts if Congress reduces Medicaid coverage, shifts coverage or funding responsibility to states, or includes a net federal reduction for Medicaid. He also voted for an amendment aimed at protecting Medicare and Medicaid coverage.
In a statement, Missouri GOP U.S. Sen. Eric Schmitt said, “as Congress looks at ways to save taxpayer dollars, accountability over the stewardship of taxpayer dollars should be our top priority.”
“This will make programs like Medicaid more sustainable and better serve the communities who need it the most,” Schmitt said.
Bell said his caucus is united against any cuts to Medicaid — which could make it harder to pass any reconciliation bill if GOP members defect.
“I've been very encouraged with the Democrats rallying around these issues,” Bell said. “Because they are issues that impact regular working-class people. These are those kitchen table issues that we're going to fight for.”
