SUPREME COURT OF MISSOURI en banc STEPHANIE DOYLE, et al., ) Opinion issued July 22, 2021 ) Appellants, ) ) LUKE BARBER and CHRISTINE ) CHANEY, ) ) Appellants, ) ) v. ) No. SC99185 ) JENNIFER TIDBALL, et al., ) ) Respondents. )
APPEAL FROM THE CIRCUIT COURT OF COLE COUNTY The Honorable Jon E. Beetem, Judge
Stephanie Doyle, Melinda Hille, and Autumn Stultz, three Missourians who are
eligible for MO HealthNet coverage under article IV, section 36(c) of the Missouri
Constitution, (“Plaintiffs”) brought suit challenging the refusal by the Department of Social
Services (“DSS”) to provide that coverage because the General Assembly failed to
appropriate adequate funding. The circuit court rejected Plaintiffs’ claims because it found
the ballot initiative that enacted article IV, section 36(c) violated article III, section 51 of
the Missouri Constitution, which prohibits initiatives from appropriating money without creating revenue to fund the initiative. Because article IV, section 36(c) does not
appropriate money and does not remove the General Assembly’s discretion in
appropriating money to MO HealthNet, the circuit court erred in declaring article IV,
section 36(c) constitutionally invalid. The circuit court’s judgment is affirmed in part and
vacated in part, and the cause remanded for the circuit court to enter judgment for the
Plaintiffs, which includes determination of the appropriate injunctive relief.
Background
For Fiscal Year 2021, Medicaid, known in Missouri as MO HealthNet, provided
health care benefits only for certain categories of low-income Missourians such as those
receiving state supplement payments for the aged, blind, and disabled; pregnant women;
children under age 19; their custodial parents; and those who are 65 and older. See section
208.151, RSMo Supp. 2019. In August 2020, however, Missouri voters approved a citizen
ballot initiative that amended the Missouri Constitution to change MO HealthNet coverage.
The initiative, now article IV, section 36(c) of the Missouri Constitution, has often been
referred to as “Medicaid expansion” because it increases MO HealthNet eligibility from
what had previously been permitted under Missouri law.
Article IV, section 36(c) defines a new category of eligible Missourians for MO
HealthNet coverage and services: adults ages 19 to 64 whose income is at or below 138%
of the federal poverty level. It is estimated this new category could include more than
275,000 Missourians. 1 Article IV, section 36(c) provides this new category of eligible
1 This number may include some individuals who previously were eligible, e.g., certain Missourians who are low-income parents, sight impaired, or disabled.
2 Missourians “shall be eligible for medical assistance under MO HealthNet and shall receive
coverage for the health benefits service package.” Further, article IV, section 36(c)
required DSS to “submit all state plan amendments necessary to implement this section to
the United States Department of Health and Human Services, Centers for Medicare and
Medicaid Services” by March 1, 2021, and to “take all actions necessary to maximize
federal financial participation in funding medical assistance pursuant to this section.”
DSS timely submitted a state plan amendment to the federal government to comply
with the requirements of article IV, section 36(c), anticipating the General Assembly would
appropriate sufficient monies to fund Medicaid expansion. The General Assembly then
considered and rejected several recommendations for separate line-item funding for
Medicaid expansion and, in the end, it appropriated money for MO HealthNet in
appropriation bills that did not reference article IV, section 36(c). As a result, DSS
withdrew its proposed state plan amendment.
The Plaintiffs filed suit against DSS and others, asserting they are eligible for MO
HealthNet coverage and services under article IV, section 36(c) and DSS is in violation of
that provision by not providing them coverage and by failing to maximize federal funding
for Medicaid. The Plaintiffs sought (1) a declaratory judgment stating DSS’ decision to
refuse to extend benefits violates article IV, section 36(c); and (2) an injunction requiring
DSS and MO HealthNet to take the steps necessary to implement article IV, section 36(c),
which includes re-filing the state plan amendment.
DSS filed an answer and alleged that, because the General Assembly did not fund
Medicaid expansion, DSS lacks authority to enroll individuals eligible under article IV,
3 section 36(c) and to disburse taxpayer money for “that purpose.” In the circuit court, DSS
stipulated it will deny MO HealthNet program benefits to individuals whose eligibility for
the program arises solely under article IV, section 36(c). It also stipulated it will not
reimburse providers for services provided to individuals whose eligibility for MO
HealthNet arises solely under article IV, section 36(c).
Luke Barber and Christine Chaney (“Proposed Intervenors”) filed a motion to
intervene as a matter of right pursuant to Rule 52.12(a)(2) and attached to their motion a
proposed petition. The proposed petition sought declaratory and injunctive relief
substantially similar to that sought by the Plaintiffs and relief pursuant to 42 U.S.C. section
1983 for alleged due process and equal protection violations. The Proposed Intervenors
subsequently filed a motion to substitute their proposed petition with one that omitted their
section 1983 allegations. The circuit court overruled the motion to intervene, finding the
Plaintiffs adequately represented the Proposed Intervenors’ interests and the delays
inherent in adding another party would prejudice the original parties.
On June 21, 2021, the circuit court conducted a trial on stipulated facts and exhibits.
The circuit court determined the initiative that resulted in article IV, section 36(c) violated
article III, section 51 of the Missouri Constitution and, therefore, was never effective. The
circuit court entered judgment in favor of DSS and the other defendants on all claims, and
4 the Plaintiffs and the Proposed Intervenors appealed. This Court has exclusive appellate
jurisdiction under article V, section 3 of the Missouri Constitution. 2
I.
The Court first addresses the Proposed Intervenors’ claim that the circuit court erred
in overruling their motion to intervene as a matter of right because the Plaintiffs do not
adequately represent their interests. The circuit court’s ruling will be affirmed “unless
there is no substantial evidence to support that decision, it is against the weight of the
evidence, or it erroneously declares or applies the law.” State ex rel. Koster v.
ConocoPhillips Co., 493 S.W.3d 397, 403 (Mo. banc 2016). An applicant seeking
intervention under Rule 52.12(a)(2) bears the burden of establishing “three elements:
(1) an interest relating to the property or transaction which is the subject of the action; (2)
that the applicant’s ability to protect the interest is impaired or impeded; and (3) that the
existing parties are inadequately representing the applicant’s interest.” Id.
The Plaintiffs and the Proposed Intervenors share the same interests. Like the
Plaintiffs, the Proposed Intervenors are individuals who are eligible for MO HealthNet
pursuant to article IV, section 36(c), and they seek to enroll in and receive health coverage
from the MO HealthNet program. Furthermore, the Proposed Intervenors sought to make
arguments in support of their petition for declaratory and injunctive relief that are
2 DSS contends the Proposed Intervenors’ appeal should have been filed in the court of appeals because it does not fall within this Court’s exclusive appellate jurisdiction. However, “when the appeal of either appealing party vests jurisdiction in this [C]ourt, the whole case must be heard here.” Walsh v. Sw. Bell Tel. Co., 52 S.W.2d 839, 840 (Mo. 1932).
5 substantially similar to the Plaintiffs’ arguments. For these reasons, the Proposed
Intervenors failed to establish the Plaintiffs will not adequately protect their interests;
therefore, the circuit court did not err in overruling their motion to intervene as a matter of
right. See id. at 405.
II.
The Court next considers the Plaintiffs’ claims. The Plaintiffs first assert the circuit
court erred in declaring article IV, section 36(c) constitutionally invalid because the
initiative did not violate article III, section 51 in that it neither appropriates money
expressly nor divests the General Assembly of its discretion by requiring it to do so. The
Plaintiffs further claim the circuit court erred in granting judgment in DSS’ favor because
article IV, section 36(c) guarantees them the right to participate in MO HealthNet and FY
2022 appropriation bills fund MO HealthNet.
The circuit court’s judgment will be affirmed “unless there is no substantial
evidence to support it, unless it is against the weight of the evidence, unless it erroneously
declares the law, or unless it erroneously applies the law.” Murphy v. Carron, 536 S.W.2d
30, 32 (Mo. banc 1976). The validity of a provision of the Missouri Constitution is a
question of law this Court reviews de novo. Peters v. Johns, 489 S.W.3d 262, 266 (Mo.
banc 2016). “This Court’s primary goal in interpreting Missouri’s constitution is to
‘ascribe to the words of a constitutional provision the meaning that the people understood
them to have when the provision was adopted.’” State v. Honeycutt, 421 S.W.3d 410, 414-
15 (Mo. banc 2013) (quoting Farmer v. Kinder, 89 S.W.3d 447, 452 (Mo. banc 2002)).
6 A. Article IV, section 36(c) does not violate article III, section 51’s prohibition against appropriation by initiative
Article III, section 51 of the Missouri Constitution provides, “The initiative shall
not be used for the appropriation of money other than of new revenues created and provided
for thereby, or for any other purpose prohibited by this constitution.” An “appropriation”
is “[a] legislative body’s . . . act of setting aside a sum of money for a specific purpose.”
Appropriation, BLACK’S LAW DICTIONARY (11th ed. 2019). Article IV, section 23 of the
Missouri Constitution requires that “[e]very appropriation law shall distinctly specify the
amount and purpose of the appropriation without reference to any other law to fix the
amount or purpose.”
By its plain language, article III, section 51 prohibits only initiatives that are used
for “the appropriation of money.” And, the plain language of article IV, section 23 makes
clear an appropriation is the authority to expend and disburse a specific amount of money
for a specified purpose. Therefore, what article III, section 51 prohibits is an initiative that
authorizes the expenditure and disbursement of a specified amount for a specified purpose
without providing new revenue. This includes an initiative that deprives the General
Assembly of discretion and requires it to appropriate money for the initiative’s purposes.
This Court has found:
Successful [article III, section 51] challenges have been limited almost exclusively to initiative petitions proposing local ordinances where the evident purpose and effect of the proposal was to impose a new obligation leaving no discretion as to whether the local governments would or could pay this new obligation and no new source of revenue sufficient to do so.
7 Boeving v. Kander, 496 S.W.3d 498, 510 n.6 (Mo. banc 2016) (emphasis added). In either
case, the focus of the analysis is on whether the initiative mandates the appropriation of
money, not whether it will require the expenditure of money to implement. Earlier cases
from this Court emphasize this point.
In Kansas City v. McGee, 269 S.W.2d 662 (Mo. 1954), this Court found an initiative
petition that proposed an ordinance creating a fireman’s pension plan violated article III,
section 51. The proposed ordinance specified that the city council “shall appropriate the
amount asked for by the trustees administering the pension plan.” Id. at 666 (emphasis
added). Although the proposed ordinance did not “in and of itself appropriate the money
to carry out the pension plan,” the Court pointed out that the proposed ordinance left no
discretion to the city council and plainly required it to appropriate money for the stated
purpose. Id. Accordingly, the Court held the proposed ordinance, in effect, required an
appropriation and, therefore, ran afoul of article III, section 51. Id. at 665.
In State ex rel. Card v. Kaufman, 517 S.W.2d 78 (Mo. 1974), this Court declined to
issue a permanent writ of mandamus requiring a mayor and city council to submit to voters
a proposed amendment to the city charter. The proposed amendment would have required
that “the salaries of members and employees of the University City Fire Department not
be less than salaries received by members and employees of the Fire Department of the
City of St. Louis.” Id. at 79. This Court found, “The obligation under the proposed
amendment would afford the officers of the city no discretion in the matter of fire
department salaries.” Id. at 80 (emphasis added). Therefore, the Court held the proposed
8 amendment “in effect is an appropriation measure” prohibited under article III, section 51.
Id.
In both McGee and Kaufman, the proposed initiatives deprived the local legislative
body of discretion by requiring it to appropriate money for the initiative’s purpose. McGee,
269 S.W.2d at 666; Kaufman, 517 S.W.2d at 80. Accordingly, article III, section 51
prohibits only initiatives that expressly appropriate money (other than newly created funds)
for its purposes or that deprive the General Assembly of discretion and require it to
appropriate money for its purposes. An initiative that simply costs money to implement
does not necessarily require the appropriation of funds so long as the General Assembly
maintains discretion in appropriating funds to implement that initiative. 3
Here, article IV, section 36(c) does not expressly appropriate money. Nothing in
article IV, section 36(c) specifically requires the General Assembly to authorize the
expenditure and disbursement of a specific amount of money for a specified purpose. See
3 The difference between substantive or general laws that require expenditures to implement and appropriations that actually implement them is clearly shown in State ex rel. Kansas City Symphony v. State, 311 S.W.3d 272 (Mo. App. 2010). There, the General Assembly enacted section 143.183.2, RSMo 1994, to provide funding for the Missouri Arts Council Trust Fund. Id. at 274. The statute provided that a percentage of a certain tax “shall be transferred from the general revenue fund to the Missouri arts council trust fund.” Id. at 277 (emphasis omitted). Eventually, the symphony filed a petition alleging the state had failed and refused to allocate the revenues required by section 143.183. Id. at 275. The court of appeals interpreted the “shall” language in section 143.183 to be directory and not mandatory because, to interpret it otherwise, would cause section 143.183 to violate article III, section 36’s prohibition on diverting funds from the treasury without an appropriation. Id. at 278. Even though an appropriation was needed to effectuate section 143.183, the General Assembly maintained discretion whether to enact that appropriation. Id. at 279.
9 Cady v. Ashcroft, 606 S.W.3d 659, 668 (Mo. App. 2020) (rejecting a pre-election challenge
that article IV, section 36(c) violates article III, section 51 because it “does not use the
phrase ‘stand appropriated’ or any similar phrase that indicates an appropriation of existing
funds or directs the legislature to appropriate such funds”). The circuit court, however,
relying on this Court’s decision in City of Kansas City v. Chastain, 420 S.W.3d 550 (Mo.
banc 2014), held the initiative had the effect of appropriating money because it would cost
money to implement and the initiative itself raised no new money for this purpose. While
that may be, nothing this Court said in Chastain suggests the mere fact an initiative will
cost money to implement violates the prohibition in article III, section 51. The question of
whether article III, section 51 prohibits anything other than an express appropriation of
money not raised by the initiative was not before this Court in Chastain. The only action
mandated by the proposed ordinance in that case was the imposition of two new sales taxes.
Id. at 556. It did not require the expenditure of those funds, nor even require the city
council to enact an appropriation authorizing their expenditure for a stated purpose. Id.
Instead, in Chastain, this Court said that article III, section 51 prohibits “an initiative
that, either expressly or through practical necessity, requires the appropriation of
funds . . . .” Id. at 555 (emphasis added). At most, Chastain suggests that – based on
McGee, Kaufman, and other decisions from this Court – an initiative violates article III,
section 51, even if it does not expressly use the word “appropriation,” when it deprives the
General Assembly of its discretion and requires it to appropriate a specified amount for the
initiative’s purpose.
10 Nothing in article IV, section 36(c) deprives the General Assembly of its discretion
and requires it to appropriate a specified amount for MO HealthNet services and benefits.
The General Assembly maintains the discretion to decide whether and to what extent it will
appropriate money for MO HealthNet programs. 4 Even though it is highly possible the
General Assembly appropriated less money than MO HealthNet programs are estimated to
cost in FY 2022, the consequences of failing to fund MO HealthNet fully at the outset or
even with a supplemental appropriation are not before this Court because they are not
relevant to whether article IV, section 36(c) violates article III, section 51. Because article
IV, section 36(c) does not expressly appropriate money for MO HealthNet nor deprive the
General Assembly of discretion and require it to appropriate money for its purposes, it does
not violate article III, section 51.
B. House Bills 10 and 11 do not contain a limitation against using the funds appropriated to provide coverage or services to individuals eligible under only article IV, section 36(c)
As explained above, the MO HealthNet eligibility criteria in article IV, section 36(c)
are valid and now in effect. The substantive law defines the scope of MO HealthNet and,
among other things, sets the eligibility criteria for participants and providers. Eligibility
4 The circuit court focused on the factors that may influence, even heavily influence, the General Assembly in determining whether and how much to appropriate for MO HealthNet in a given year. The consequences of whether and how much to appropriate for any particular purpose from the nearly $33 billion at the General Assembly’s disposal can – and nearly always will – weigh heavily in the General Assembly’s deliberations. But, those considerations – like the decisions themselves – belong to the General Assembly and not to this Court, and the consequences of appropriations that turn out to be less than the full cost of MO HealthNet for FY 2022 are not before the Court in this case.
11 for MO HealthNet was previously a matter of statute but, now, that substantive law
includes article IV, section 36(c). The substantive law does not, however, determine
whether and how much funding to authorize for MO HealthNet in a given year. That
determination is left to the discretion of the General Assembly in its appropriation process.
DSS contends that in the MO HealthNet FY 2022 appropriation bills the General
Assembly implicitly exercised discretion to require that none of the appropriated funds be
used to provide coverage or services to individuals who would be eligible for MO
HealthNet only pursuant to article IV, section 36(c). There is, however, no such limitation
in House Bills 10, 11, or other MO HealthNet FY 2022 appropriation bills.
Appropriations consist of both a specified amount and a specified purpose, see Mo
Const. art. IV, sec. 23, and the appropriations in House Bills 10 and 11 expressly state what
their purposes are. DSS highlights several appropriations in House Bill 11 to bring the
Court’s attention to the appropriated proportion of federal to state funds. In doing so,
however, it ignores the expressly stated purpose of each appropriation. For example,
section 11.715 of HB 11 specifies its purpose is “[f]or the MO HealthNet Division . . . [f]or
physician services and related services including, but not limited to” various covered
medical services; section 11.720 of HB 11 states its purpose is for “the MO HealthNet
Division . . . [f]or dental services under the MO HealthNet fee-for-service program”;
section 11.750 states it is for “the MO HealthNet Division . . . [f]or payments to providers
of ground emergency medical transportation”; section 11.760’s purpose is for “the MO
HealthNet Division . . . [f]or payment to comprehensive prepaid health care plans as
provided by federal or state law or for payments to programs authorized by the Frail Elderly
12 Demonstration Project Waiver”; 5 and section 11.765 states its purpose is for “the MO
HealthNet Division . . . [f]or hospital care under the MO HealthNet fee-for-service
program, graduate medical education, and for a comprehensive chronic care risk
management program . . . .” Clearly, the bills fund services to all who are eligible for MO
HealthNet, and they do not purport to exclude those eligible only pursuant to article IV,
section 36(c).
Because DSS’ interpretation of House Bills 10, 11, and the other MO HealthNet FY
2022 appropriation bills conflicts with the plain language of those bills, this Court declines
to adopt that interpretation, which was described by the circuit court as “semantic and legal
gymnastics.” 6 When, as here, the language of a statute is plain and unambiguous, the Court
“must give effect to the language as written,” Norris v. Dir. of Revenue, 304 S.W.3d 724,
726 (Mo. banc 2010), and “extrinsic aids to statutory construction cannot be used,”
Farmers’ & Laborers’ Coop. Ins. Ass’n v. Dir. of Revenue, 742 S.W.2d 141, 143 (Mo.
5 DSS claims section 11.760 of HB 11 evidences a purpose to fund only the pre-expansion population because it contains a reference to “MO HealthNet eligibles described in Section 501(a)(1)(D) of Title V of the Social Security Act,” i.e., the pre-expansion population. Section 11.760, however, merely ensures those eligible “may voluntarily enroll in the Managed Care Program[.]” It does not purport to restrict its funding to the pre-expansion population. 6 Because the plain and ordinary language of MO HealthNet FY 2022 appropriation bills does not restrict funding for coverage or services provided by article IV, section 36(c), the Court does not address whether such restrictions would violate this Court’s holding in Planned Parenthood of St. Louis Region v. Department of Social Services, Division of Medical Services, 602 S.W.3d 201, 211 (Mo. banc 2020) (“Any attempt to use an appropriation bill to amend such general laws necessarily runs afoul of the multiple subject prohibition in article III, section 23 of the Missouri Constitution.”). For the same reason, this Court need not consider DSS’ argument that this Court should overrule its recent decision in Planned Parenthood.
13 banc 1988). In the end, this “Court refrains from adding words to the statute” under the
guise of construction. Treasurer of State v. Parker, 622 S.W.3d 178, 181 (Mo. banc 2021).
With no ambiguity, the amounts appropriated and other extrinsic evidence cannot be used
to alter the plain language of the purposes stated – to fund MO HealthNet without
distinguishing between benefits provided to individuals who are eligible as part of the pre-
expansion population and those eligible only under article IV, section 36(c).
The General Assembly chose to appropriate funds for the MO HealthNet programs
for FY 2022. This was one of presumably thousands of difficult decisions made each year
during the appropriation process. But, having made this decision, DSS and MO HealthNet
are bound by article IV, section 36(c) concerning which individuals are eligible to enroll
when it spends the appropriated funds. Consequently, DSS has appropriation authority to
provide services for all individuals eligible for MO HealthNet, including individuals
eligible for coverage and services pursuant to article IV, section 36(c).
Conclusion
For the reasons set forth above, the circuit court’s judgment is affirmed only insofar
as it overruled the Proposed Intervenors’ motion to intervene. In all other respects, the
judgment is vacated, and the cause is remanded to the circuit court to enter judgment for
the Plaintiffs, which includes determination of the appropriate injunctive relief.
All concur.