My objections to expanding Medicaid in Missouri were both fiscal and structural. Expansion was not a jobs program; it would commit future taxpayers to paying for services today. State costs were projected in the billions over the coming decade, yet proponents had not shown how Missouri would finance them—especially if federal support later declined.

Nor was it true that rejecting expansion meant other states would simply receive “Missouri's money.” Federal expansion funding followed enrollment rather than being divided from a fixed state-by-state pot.

The proposal also raised a larger question about the role of state government. Medicaid was projected to consume an enormous share of Missouri's budget, making the state increasingly dependent on federal policy and funding. Moody's had already expressed concern about Missouri's exposure to federal dollars.

Instead of expanding an already troubled entitlement, legislators should focus on improving the Medicaid program Missouri already has. Serious reform requires a sustainable financing plan and better care, not simply a larger program.