David A. Lieb/AP Photo
Healthcare for Missouri campaign workers deliver boxes of initiative petition signatures to the Missouri secretary of state’s office in Jefferson City, Missouri, May 2020.
With the pandemic raging and unemployment soaring, the 37 states and the District of Columbia that implemented the Obamacare Medicaid expansion are better positioned to weather one of the most disastrous periods in United States history than the holdouts. Missouri was one of the mostly conservative Republican states that held back. Six of the eight Midwest states that border Missouri have expanded Medicaid, however; most recently Oklahoma, a bastion of conservatism, narrowly voted to join the expansion cohort.
Missourians go to the polls on Tuesday, August 4, to vote on Amendment 2, a ballot initiative that would enshrine Medicaid expansion in the state constitution, delivering health insurance coverage to eligible residents.
Perhaps the most remarkable aspect of the Medicaid expansion debate in a deep-red state like Missouri is the appeal of a program that has been vilified for its entire existence by national and state Republican leaders. But the new alliances created by the expansion push signal how dire the health insurance situation is for Missourians.
Just two years ago, business leaders and union officials were engaged in a bitter right-to-work ballot initiative contest that saw unions prevail. This year finds the AFL-CIO, the Missouri Chamber of Commerce and Industry, and the Springfield Area Chamber of Commerce (located in one of the most conservative regions of the state) all touting the job-creating benefits of expansion, locking arms with the state chapters of the NAACP, AARP, Missouri Catholic Conference, and associations representing doctors, nurses, and hospitals.
As the pandemic has thrown states into chaos, the Affordable Care Act is proving to be a lifeline for many Americans. Of the tens of millions of Americans who have lost their jobs, people who live in expansion states are able to take advantage of the ACA safety net. In non-expansion states like Missouri, many residents can end up with no coverage at all. In Missouri, unemployment in May was 10 percent, according to the state Department of Labor, with 117,000 claims filed. (Through the first four weeks of July, roughly 61,000 claims had been filed.)
A “yes” vote on Amendment 2 would deliver health care to about 250,000 residents whose incomes fall below 138 percent of the federal poverty level, about $17,600 for an individual and $36,400 for a family of four. Currently, incomes above 100 percent of poverty are ineligible for Medicaid.
Proponents of the measure had to collect 170,000 signatures to get it on the ballot; they ended up with nearly 350,000.
Under the ACA, the federal government pays 90 percent of expansion costs, and the state pays 10 percent. Missouri has already lost out on significant federal funding. Since 2013, Missouri residents have paid about $10 billion in taxes and received zero dollars in benefits for expanded Medicaid, while their tax dollars flow to other states’ expansion programs. Those figures have helped Amendment 2 supporters whittle away at opponents’ claims that the state cannot afford additional expenses to fund the state portion of expansion without tax increases that residents abhor. (Under the 1980 Hancock Amendment, most tax increases must go before voters.)
Missouri has also been at the forefront of the rural hospital closure crisis. Since 2014, ten rural hospitals have closed; nearly 30 others are at risk. Supporters of the expansion measure say that funneling federal dollars into the state may help stem some of those losses and create new jobs in rural communities.
Proponents of the measure had to collect 170,000 signatures to get it on the ballot; they ended up with nearly 350,000. The pandemic may reduce turnout (Missouri does not have a robust vote-by-mail framework), which points to a close vote; others, however, see the broad coalition as evidence that the result will be decisive.
Missouri state officials maneuvered to keep the initiative off the November ballot, when turnout would be higher. Instead of using a verification process that would have sent signatures to local election officials to evaluate, likely pushing the counting out beyond the deadline for the August primary, state officials sampled a smaller number of signatures and quickly qualified the measure for August.
They are “engineering an election to be as hard as possible for Medicaid expansion to win,” says Jonathan Schleifer, executive director of The Fairness Project, a major funder of the “Yes on 2” coalition and successful Medicaid expansion ballot initiative campaigns in Idaho, Maine, Nebraska, Oklahoma, and Utah. He declined to say how much the project contributed to Yes on 2, adding only that the group would divulge its spending after the vote. Supporters of the initiative have poured more than $10 million into the contest. A one-man-band lobbyist, Travis Brown of Pelopidas LLC, is the sole donor for the “No on 2” campaign, contributing nearly $112,000.
Putting a health care measure on the November ballot would have posed more trouble for the embattled GOP Gov. Mike Parsons, who is now locked in a tight re-election race against Democratic State Auditor Nicole Galloway, a race that was once expected to be a breeze for the incumbent.
The pandemic upended that calculation. “His hands-off approach to let localities deal with the virus [initially] sat well with a lot of people,” says Robynn Kuhlmann, an associate professor of political science at the University of Central Missouri. But Kuhlmann notes that voters are now largely split over his handling of the public-health crisis, and Galloway has pulled into a statistical dead heat in the governor’s race.
Not only has unemployment jumped in Missouri, it’s now a “red zone” state, with 100 new COVID-19 cases per 100,000 people in the past seven days. The pandemic has laid bare the fragile relationship between employment and health insurance that has imperiled the lives of thousands of people in Missouri and the 12 other states that have failed to adopt this modest health care reform. After Tuesday, that number could drop by one.
