For the seventh time in three years, voters will have an opportunity to provide health coverage to poor adults whom Republican leaders have failed to serve as Missourans decide whether to amend the state’s Constitution to guarantee access to Medicaid on Aug. 4. 

The proposed change, backed by progressive activists and business groups, would expand MO HealthNet, as Medicaid is called in the state, to anyone earning less than 133% of the federal poverty level, which is about $17,000 a year for a single person. This Medicaid expansion is made possible by the 2010 Affordable Care Act, which provides 90% federal funding to cover the newly eligible people. If the Show-Me State approves, it would be the sixth to do so via popular ballot.

As many as 458,000 adult Missourians could qualify for Medicaid coverage under the expansion, including 190,000 who are currently uninsured, according to an analysis by Washington University in St. Louis. 

The remainder would be low-income people who are now paying for private insurance either through an employer or the Affordable Care Act’s health insurance exchange marketplace. Washington University also projects that Medicaid expansion would help prevent cuts to other state health care programs, resulting in an overall savings for the state.

“They’ve waited more than long enough, and we’re still not seeing any indication that our legislature wants to do it, so we’re taking it to the people,” said Jen Bersdale, executive director of Missouri Health Care for All in St. Louis. “It’s unfortunate that we have elected leaders who are trying to portray a false choice between health care for hardworking families and other priorities, especially a legislature that continues to push through tax cuts.”

Missouri Is Trump Country

Missouri is a conservative state with a Republican governor and GOP control of the state legislature and opposed to Medicaid expansion. In addition, six of its eight representatives to the U.S. House are Republicans, as are both of its U.S. senators. And President Donald Trump soundly defeated Democratic presidential nominee Hillary Clinton in 2016 with 57% of the vote.

Those are obstacles supporters of Medicaid expansion must overcome, as are the challenges of winning on a progressive issue on a primary election day that’s likely to attract more Republicans to the polls than Democrats and amid the novel coronavirus pandemic. Missourians have limited access to vote-by-mail.

Nevertheless, the Medicaid expansion ballot initiative has a real chance at passing, just as it did in Oklahoma and other conservative states, said Jake Haselswerdt, a political science professor at the University of Missouri in Columbia. 

Haselswerdt noted that two years ago, Missouri voters passed initiatives to raise the minimum wage, make medical marijuana legal, reform congressional redistricting and repeal a “right to work” law that would have weakened labor unions. The Republican establishment opposed all of the measures

“There’s also this recent history of Medicaid expansion passing in other red and purple states,” he said. “The people involved in both of those are involved in this. So the progressive community knows what it’s doing at this point.”

“Voters are not following the signals of politicians anymore on many, many issues, especially ones that are profoundly tied to their well-being and their neighbors’ well-being, and they’re willing to reject the dogma of the Republican Party and the ideology that has said we need to keep wages low and minimize the social safety net,” said Jonathan Schleifer, executive director of the Fairness Project, a Washington-based organization that specializes in ballot initiatives for progressive policies like Medicaid expansion and minimum-wage increases.

The Fairness Project participated in the winning campaign to raise Missouri’s minimum wage. “Americans actually agree on a lot of things when it comes to wages and health care and how they should be treated by their employers. But that is lost in politics,” Schleifer said. “They don’t have to go begging for what’s right from politicians. They can go have reasonable conversations with their neighbors about this policy and they can get what they like.”

Red State Victories

Oklahoma voters approved a similar Medicaid measure earlier this month, following a successful ballot initiative in Maine in 2017 and the enactment of Medicaid expansion by voters in Idaho, Nebraska and Utah in 2018. An effort to keep Montana’s Medicaid expansion in place failed two years ago, but Gov. Steve Bullock (D) signed legislation into law in 2019 to achieve the same result.

President Barack Obama and the congressional Democrats who authored the Medicaid expansion intended it to be nationwide, but a 2012 Supreme Court ruling made it optional for states. Missouri remains among the 13 states that have not adopted Medicaid expansion. Medicaid is jointly operated and financed by the federal government and the states.

The Supreme Court ruling sparked the expansion campaign, Bersdale said. Initially, even some Republican state legislators seemed open to a deal on Medicaid expansion, she said. That didn’t last. “We just started having more and more proverbial and literal doors shut in our face. Members of the majority party in Missouri just decided they weren’t going to talk about this issue.”

David A. Lieb/Associated Press

Campaign workers David Woodruff (left) and Jason White deliver boxes of initiative petition signatures to the Missouri secretary of state’s office in Jefferson City on May 1. The Healthcare for Missouri campaign said it gathered nearly 350,000 signatures for a proposed constitutional amendment expanding Medicaid coverage.

Missouri Gov. Mike Parson (R) opposes Medicaid expansion, as did his GOP predecessor, Eric Greitens. Parson even scheduled the Medicaid vote for August rather than on Election Day in November, when both he and Trump are up for reelection. 

Republicans have supermajorities in the state House and state Senate and have shown little interest in providing health benefits to more low-income adults. Former Gov. Jay Nixon (D) promoted Medicaid expansion until term limits ended his tenure in 2016, but GOP lawmakers were unpersuaded.

A group called Healthcare for Missouri is leading the campaign to pass the ballot initiative and organized the campaign to collect enough signatures to get the constitutional amendment in front of voters. Activists were able to complete this crucial step before the pandemic could derail the effort, which has happened to other organizations seeking to place matters on the ballot this year. Healthcare for Missouri did not respond to interview requests.

In addition to local and national progressive organizations, the Medicaid expansion ballot initiative has a slew of supporters, including the Missouri Chamber of Commerce and Industry, the Missouri Hospital Association and the Missouri State Medical Association. The pro-expansion side also has received assistance from the Fairness Project.

The main opponents are elected Republicans and conservative ideological organizations, including Americans for Prosperity and the Show-Me Institute

A Meager Safety Net

Nine percent of Missouri residents are uninsured, the same as the national rate, according to census data compiled by the Henry J. Kaiser Family Foundation. 

But the state has one of the most restrictive Medicaid programs in the U.S. Adults who do not have disabilities and who do not have minor children living at home cannot qualify for Medicaid coverage no matter how little they earn. 

Missouri parents are eligible only if their annual incomes don’t exceed 21% of the poverty level, which amounts to about $2,700; only Alabama and Texas have lower income ceilings for Medicaid coverage of parents. Adults with disabilities can qualify only if their annual income is at or below about $11,000 a year for a single person.

And over the past year or so, Missouri’s government has attracted unfavorable attention for a purge of children and parents from the state’s Medicaid rolls, which is part of a broader trend under the Trump administration’s management of the program.

Even a victory next month on Medicaid expansion likely won’t be the end of the issue in Missouri. As an illustration, the state’s legislators currently are attempting to get voters to undo major parts of the redistricting reforms that passed at the ballot box in 2018.

The recent history after the Medicaid expansion votes in Maine, Idaho, Utah and Nebraska also are instructive. Then-Gov. Paul LePage (R) of Maine refused to carry out the law voters passed, delaying expansion until after he left office in 2019. The GOP leaders of Idaho and Utah altered the Medicaid expansion that citizens backed by adding restrictions to the program.

“We are certainly prepared to do whatever it takes to get this implemented,” Bersdale said. “We’ve certainly seen times that they tried to circumvent the will of the voters, but I hope that on this one they won’t.”

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