WASHINGTON — In 2018, then-Missouri Lawyer Normal Josh Hawley signed on to multistate litigation looking for to overturn the 2010 well being care regulation — a transfer that, if profitable, would have eradicated protections for individuals with preexisting situations and ended the growth of Medicaid to hundreds of thousands of low-income individuals.
Now, because the senior senator representing Missouri, Hawley finds himself within the unlikely place of defending Medicaid as his fellow Republicans scour for $880 billion to assist prolong President Donald Trump’s tax cuts and pay for elevated funding for border safety.
Hawley has made his stance clear in current weeks: He won’t help any proposal that might result in cuts in Medicaid advantages for Missourians.
“I just want to know, at the end of the day, whatever reforms or packages of things proposed, will it result in reductions to benefits to Missourians? That’s my test.”
What’s modified for Hawley, a longtime critic of the 2010 well being care regulation?
Poll measure
In 2020, a majority of Missouri voters accepted a poll measure to broaden Medicaid within the state to cowl greater than 348,000 adults making $21,597 a 12 months or much less.
“Our voters voted for it. It’s not like the legislature can just adjust it. It’s in our constitution. Our voters voted for it by a big margin,” Hawley mentioned in an interview.
It’s an sudden about-face for Hawley, a conservative senator with a long-held opposition to the 2010 well being care act and an 85% ranking from the Conservative Political Motion Convention.
“Sen. Hawley is among the most surprising defenders of Medicaid among Republicans in Congress given his past positions,” mentioned Larry Levitt, government vice chairman at KFF, a well being coverage analysis group.
Price range modification
Final week, Hawley joined Oregon Democratic Sen. Ron Wyden in introducing an modification to the funds decision that might strip an instruction to the Home Vitality and Commerce Committee to search out $880 billion in financial savings, most of which might probably want to return from Medicaid. The modification was not adopted.
Solely two different Republicans voted for it: Sens. Susan Collins of Maine and Lisa Murkowski of Alaska. Each additionally opposed 2017 efforts to repeal the 2010 well being care regulation.
Nonetheless, all three Republicans mentioned they’re open to instituting work necessities in Medicaid, which critics say is a method to the identical finish: saving cash through individuals dropping protection.
A Congressional Price range Workplace estimate of that provision acknowledged that by implementing the Medicaid work necessities, “the employment status of and hours worked by Medicaid recipients would be unchanged, and state costs would increase,” whereas federal prices would lower by $109 billion over 10 years. About 600,000 individuals might change into uninsured, the CBO projected.
“Work requirements — I want to be clear — I’m for,” mentioned Hawley, who mentioned he has a dedication from Trump to not signal a invoice that might lower Medicaid advantages. “But beyond that, actual benefit cuts, no, I’m not going to vote for that.”
On the entire, Republicans, together with Hawley, have lengthy opposed increasing Medicaid, with state legislators resisting doing so for a number of years after the 2010 well being care regulation allowed the states the choice, even with the federal authorities selecting up 90% of the prices.
However voters really feel in a different way, evidenced by voters in seven states with Republican governors approving Medicaid growth by poll initiatives.
“To some extent, the political dynamics we’re seeing on Medicaid are a reflection of the changing Republican political base. … Particularly with the emergence of President Trump, the Republican base has shifted more toward lower-income, working-class people, many of whom rely on Medicaid for coverage,” Levitt mentioned.
Increasing Medicaid in pink states has constructed political salience for this system and made it harder for Republican lawmakers to chop it, mentioned Kelly Corridor, government director of the Equity Undertaking, which helped launch the Medicaid growth poll initiative campaigns.
“This is not the last time we’ll have to fight this fight, and next time, we need more Republicans,” Corridor mentioned she thought in 2017 when former Sen. John McCain, R-Ariz., blocked the repeal of the well being care regulation with a now-famous thumbs-down movement.
“To have a conversation in 2025 where we’re talking about not just the millions of people who have gotten Medicaid coverage thanks to those ballot measures, but seeing Josh Hawley, who was no friend of the [health care law] for most of his career, now standing and saying, ‘I’m going to oppose Medicaid cuts because of what it means for my state,’ to me, that is so gratifying,” Corridor mentioned.
“It really does represent this important notion of when you expand Medicaid anywhere, you help protect it everywhere.”
Enshrined in state constitutions
Missouri is likely one of the three states, together with Oklahoma and South Dakota, the place voters not solely expanded Medicaid but additionally enshrined it within the state’s structure. Which means if the federal share of funding for the growth inhabitants had been to drop, Missouri must discover different methods to pay for it.
“A state like Missouri would have to continue with expansion, leading to a huge cost shift to the state,” Levitt mentioned.
Legislators in some states are already toying with the thought of rolling again growth, fueled by ideological opposition to it but additionally by worry of how the actions of Congress would possibly affect their budgets.
However in Missouri, certain by the structure to retain Medicaid growth, Gov. Mike Kehoe, a Republican, advised Hawley any “significant” adjustments to the federal match fee might blow a $1 billion greenback gap within the state’s funds.
Advocates fear that as a result of the state wouldn’t have the ability to lower advantages to the growth inhabitants, they could pursue cost-saving measures for different populations that states don’t should cowl beneath the regulation, primarily youngsters, pregnant individuals and older adults who make greater than the federal poverty stage. For instance, through the 2003 and 2008 recessions, some states lower or froze reimbursement charges to suppliers and lower “optional” advantages not required by regulation, like home- and community-based companies, dental and imaginative and prescient care.
Charge cuts or freezes might end in suppliers not accepting Medicaid — already an ongoing difficulty in Missouri and elsewhere.
“People might say we’re not going to cut that, but my concern, especially because of the constitutional amendment in Missouri, are the populations that would be available to cut would primarily be seniors and people with disabilities that are not necessarily part of the expansion population,” mentioned Richard von Glahn, coverage director of the left-leaning Missouri Jobs with Justice, which helped arrange the state’s Medicaid growth poll query.
Elective companies coated by Missouri Medicaid embody dental, in-home care, pharmacy advantages, medical tools and extra.
In Missouri, 26% of state expenditures go towards Medicaid — one of many highest charges within the nation. Medicaid protection is widespread in Missouri, protecting one-fifth of the inhabitants, or 1.3 million individuals, together with 2 in 3 nursing residence residents, 1 in 6 Medicare beneficiaries and 40% of births.
Regardless of the talk about the price of Medicaid growth, most expenditures go towards older adults and other people with disabilities who usually tend to have greater well being care prices.
Hawley mentioned he additionally wouldn’t help laws that shifts prices to states.
“We’re a balanced-budget state, which is great. I support that. But that would mean massive benefit cuts,” Hawley mentioned.
