A plan to add Medicaid work requirements to the state Constitution was debated by a Missouri House committee this week, with Republican lawmakers hoping to put the issue before voters later this year.
The proposed ballot measure, if approved by a majority of Missouri voters, would make it more difficult for the state to reverse federal restrictions on Medicaid eligibility included in the One Big Beautiful Bill Act passed by Congress this summer if those requirements change in the future.
“The reality of it is this is coming to Missouri, irrespective of this,” said state Rep. Darin Chappell, a Rogersville Republican sponsoring legislation that would propose the change. “This is just saying we should keep it that way.”
Starting Jan. 1, 2027, the federal law will require adults ages 19 to 64 who are covered as part of Medicaid expansion to show that they work, volunteer or study at least 80 hours a month to qualify for the health care program for low-income people. The law also requires states to recertify enrollees’ eligibility every six months instead of once a year.
With Missouri’s Department of Social Services requesting an additional $131 million to cover costs this fiscal year of implementing the federal law, state lawmakers debated during the Tuesday hearing of the House Legislative Review Committee whether work requirements would slash MO HealthNet costs or add to the expense of implementing the federal law.
Chappell said the intent of his legislation is “to mirror what has been done at the national level already.” He believes the constitutional amendment would save Missouri money.
“There will be individuals who were not the original intent of Medicaid and choose not to engage in the work requirements that will not have access to Medicaid any longer,” Chappell told The Independent.
Medicaid eligibility changes in the federal law could cause 130,000 Missourians to become uninsured in the next decade, according to one estimate from Princeton University. There were 363,641 MO HealthNet adult expansion enrollees in December, an all-time high, according to data from the state social services department.
The ballot measure described in Chappell’s joint resolution is not identical to changes the federal law makes to Medicaid eligibility. While the measure would require the Missouri Department of Social Services to go back three months in an individual’s employment history to verify that they meet work requirements, the federal law only requires states to check one month prior to enrollment. And Chappell left open how often the department would have to verify that current enrollees are still meeting requirements.
“Some of this is going to have to be departmental capacity,” Chappell said. “I don’t know that it’s every 30 days.”
Democrats insisted the fiscal note attached to the legislation didn’t reveal the full costs of the changes and questioned why lawmakers should amend a section of the state constitution recently changed by a popular vote of Missourians.
Missourians voted in 2020 to expand Medicaid, opening eligibility to people earning up to 138% of the federal poverty level, though enrollment did not begin until Oct. 2021 because state lawmakers refused to fund it.
State Rep. Aaron Crossley, a Democrat from Independence, asked Chappell if he had considered a “trigger law” that would change statute to reflect the federal law, but only as long as the federal law remains in force.
“Why not do that and then say, ‘OK, we’ll go back to what the voters approved a few years ago when federal law likely changes?” Crossley said.
Chappell emphasized that if his bill passes, voters will have final say about the constitutional amendment.
“If we believe in the will of the people, as I certainly do, why are we so afraid to let them speak again, to modify what’s already been said?” Chappell said in an interview with The Independent. “How is that horrible?”
The fiscal note included only the projected cost of putting Chappell’s proposal on the ballot in November, which comes out to roughly $9 million.
But State Rep. Jo Doll, a Democrat from St. Louis, said that if voters approved the measure, the cost to the state would be much higher.
“Where are we going to find the workers?” Doll said. “Because it’s going to take a lot of people to verify that someone has been working for three months prior and every month following.”
Gov. Mike Kehoe’s executive budget for fiscal year 2027 recommends a reduction of 238 staff in the state’s social services department, which is in charge of eligibility and enrollment for MO HealthNet. The recommended cut includes a reduction of 173 “income maintenance” staff, who according to a description in the department’s budget request, “determine eligibility for assistance programs.”
In its supplemental budget request for the current fiscal year, the department asked for an additional $9 million in state general revenue and $123 million in federal funds to implement the federal law — partly to pay for income maintenance system updates. The department requested another $530 million to cover the adult expansion Medicaid population.
Chappell underlined that the ballot measure would not affect people exempt from federal work requirements due to disability or pregnancy.
But Crossley, who works in health care and has helped clients apply for Medicaid, said he has seen people lose coverage for administrative reasons that they were legally entitled to.
“If they miss one piece of mail and it’s time for them to renew their Medicaid…[or] they miss that one notification, then they’re off their insurance,” Crossley said.
Chappell acknowledged that some costs of more uncompensated care as more Missourians go uninsured could fall to taxpayers, but he said he believes the constitutional amendment would help people in the long run.
“If we encourage people to go to work, and we change the dynamic of their world view…so that they become part of the working population, I think we’ll see that they’ll increase their money that’s available to them,” Chappell told The Independent. “They’ll create for themselves skill sets whereby they can get employed and thereby have healthcare access through their employers.”