Missouri Amendment 2, Medicaid Expansion Initiative (August 2020)

Missouri Amendment 2
Election date August 4, 2020
Topic Healthcare
Status a Approved
Type Constitutional amendment	Origin Citizens
List of Missouri measuresMissouri Amendment 1Missouri Amendment 2Missouri Amendment 3Submit

Missouri Amendment 2, the Medicaid Expansion Initiative was on the ballot in Missouri as an initiated constitutional amendment on August 4, 2020. It was approved and upheld by the Missouri Supreme Court. Click here to read more about the lawsuit and ruling.

A "yes" vote supports: expanding Medicaid eligibility in Missouri to adults that are 19 years old or older and younger than 65 whose income is 133% of the federal poverty level or below, which would effectively expand Medicaid to those with incomes at or below 138% of the federal poverty level under the Affordable Care Act; prohibiting any additional restrictions or requirements for the expanded population to qualify for Medicaid coverage than for other populations that qualify for Medicaid coverage; and requiring the state to seek maximum federal funding of Medicaid expansion.

A "no" vote opposes this constitutional amendment to expand Medicaid eligibility in Missouri under the Affordable Care Act.

Election results

Missouri Amendment 2
Result		Votes	Percentage
Yes		676,687	53.27%
No		593,491	46.73%

Results are officially certified.

Source

Overview

Who becomes eligible for Medicaid coverage under Amendment 2?

See also: Text of measure

Amendment 2 expanded Medicaid eligibility in Missouri to adults that are between the ages of 19 and 65 whose income is 138% of the federal poverty level or below. The Affordable Care Act expanded Medicaid to individuals with income at or below 133% plus an additional 5% income disregard, which effectively set the maximum at 138%. In 2020, this amounted to an annual income of $17,608 for an individual and $36,156 for a household of four. The amendment prohibited any additional restrictions or requirements for the expanded population to qualify for Medicaid coverage than for other populations that qualify for Medicaid coverage.

Amendment 2 required the Missouri Department of Social Services and the Missouri HealthNet Division to submit state Medicaid plan amendments by March 1, 2021, to the U.S. Centers for Medicare and Medicaid Services to implement Medicaid expansion.

What populations were eligible for Medicaid prior to the approval of Amendment 2?

See also: Medicaid in Missouri

The following populations were eligible for Medicaid at the time of the election in Missouri:

• Over 65 years of age,
• Blind or disabled,
• Adults with dependent children with a household income at or below 22 percent of the federal poverty level,
• Infants under the age of one in a household with an income at or below 196 percent of the federal poverty level,
• Children between the ages of one to 18 in a household with an income at or below 150 percent of the federal poverty level, and
• Pregnant women with a household income at or below 196 percent of the federal poverty level.

How is Amendment 2 related to the Affordable Care Act?

See also: Medicaid expansion under the ACA

Medicaid is a government program that provides medical insurance to groups of low-income people and individuals with disabilities. The Affordable Care Act (ACA), also known as Obamacare, provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level. In 2012, the U.S. Supreme Court ruled in NFIB v. Sebelius that the federal government could not withhold funds from states that refused to expand Medicaid. The ruling had the practical effect of making Medicaid expansion optional for states. For 2020 and subsequent years, the federal government was set to cover 90 percent of the costs. As of 2020, a total of 37 states and Washington, D.C., had expanded or voted to expand Medicaid, while 13 states had not.

Who was behind the campaigns surrounding Amendment 2?

See also: Support and Opposition

Healthcare for Missouri led the Yes on 2 campaign in support of the amendment. There were two political action committees, Healthcare for Missouri and Missourians for Healthcare, registered to support Amendment 2. The committees raised $10.7 million, with Missourians for Healthcare receiving the bulk of the contributions. The top five donors to the campaign included the Missouri Hospital Association, the North Fund, the Health Care Issues Committee of the Missouri Hospital Association, the Health Forward Foundation, and The Fairness Project.

The support campaign argued that the coronavirus pandemic has shown the need for Medicaid expansion. Jack Cardetti, a spokesperson for the Yes on 2 campaign, said, "Now more than ever, Missourians need to be able to access care in their own communities and protect thousands of local frontline healthcare jobs. ... Amendment 2 will help keep rural hospitals and urban clinics open by bringing $1 billion of our own tax dollars back from Washington, instead of going to the 37 other states that have expanded Medicaid."

No on 2 in August led the campaign in opposition to Amendment 2. The campaign reported receiving $463,344.04 in contributions. State Senator Bob Onder (R-2) said, "The money needed to expand Medicaid is going to come from somewhere. It either has to come from education, from roads or from massive tax increases. ... I do think that Missourians, particularly in these challenging economic times, will realize that a massive expansion of the Medicaid program isn’t something that we can afford."

What other states have voted on Medicaid?

See also: Medicaid expansion in 2018

In 2017, Maine was the first state to vote on a ballot initiative to expand Medicaid. Maine's 2017 measure was approved. In 2018, ballot initiatives to expand Medicaid in Utah, Nebraska, and Idaho were approved. A 2018 initiative in Montana that would have renewed Medicaid expansion and increased tobacco taxes was defeated. On June 30, 2020, Oklahoma approved an initiative to expand Medicaid. It was approved 50.5% to 49.5%.

Aftermath

House Bill 20 (HB 20) was introduced on February 24, 2021. It was designed to provide funding for the expansion of Medicaid in the state. On March 25, it was voted down in the House Budget Committee with 20 members opposing and nine supporting the bill.

On April 28, the Missouri State Senate also voted against funding expansion by defeating an amendment to House Bill 10 (HB 10), which was designed to appropriate money for the Departments of Mental Health and Health and Senior Services. The vote margin was 14 in favor of the amendment and 20 against.

On May 13, 2021, Governor Mike Parson (R) announced that his administration had withdrawn its request to expand Medicaid in the state from the federal Centers for Medicare and Medicaid Services. Gov. Parson said, "Without a revenue source or funding authority from the General Assembly, we are unable to proceed with the expansion at this time and must withdraw our State Plan Amendments to ensure Missouri’s existing MO HealthNet program remains solvent." Richard von Glahn, policy director for Missouri Jobs With Justice, one of the organizations that supported Medicaid expansion, said, "This is going to end up in court — the governor knows it’s going to end up in court."

Lawsuit

  

Lawsuit overview
Issue: Whether the Department of Social Services has to provide Medicaid to individuals that qualify under the 2020 initiative even if the legislature did not appropriate additional funds to expand Medicaid eligibility
Court: Cole County Circuit Court
Ruling: The amendment is constitutional
Plaintiff(s): Stephanie Doyle, Melinda Hille, and Autumn Stultz	Defendant(s): Jennifer Tidball, Missouri Department of Social Services; Kirk Matthews, Missouri Healthnet Division; and Kim Evans, Department of Social Services-Family Support Division
Plaintiff argument: The state must allow the three plaintiffs to enroll in Medicaid per the expanded eligibility authorized by Amendment 2 and receive the same coverage as existing enrollees	Defendant argument: The agencies responsible for Medicaid administration cannot allow them to enroll since the legislature did not appropriate funding for the expansion

  Source: Missouri Independent

On May 20, 2021, Stephanie Doyle, Melinda Hille, and Autumn Stultz, three individuals who would all qualify for Medicaid under the expanded eligibility under Amendment 2, filed a lawsuit in Cole County Circuit Court against the state's Department of Social Services and the Missouri Healthnet Division asking the court to allow them to enroll in Medicaid and receive the same benefits as existing enrollees.

The lawsuit says, "The agencies claim that they lack the authority to implement Medicaid expansion because the General Assembly did not include a specific appropriations line item funding services for the newly eligible population. This position has no merit. ... Nothing in the Department of Social Services appropriations bill prevents the agencies from using appropriated funds to cover individuals whose eligibility arises under the constitution."

On June 7, 2021, John Sauer, an attorney for the state, responded to the lawsuit arguing, "The legislative branch has exclusive authority over appropriations under the Missouri Constitution. ... The availability of additional federal funds to offset some of the costs of Medicaid expansion alleged in the petition does not make up for the lack of appropriations authority under state law to expend any funds whether state or federal, for the purpose of Medicaid expansion." The case was set to be heard on June 21, 2021.

On June 23, 2021, Judge Jon Beetem ruled that the amendment was unconstitutional because it did not include a way for the state to pay for the Medicaid expansion. He wrote, "If the court allows them to spend other state revenues by initiative such action would deprive the General Assembly of its constitutional right to appropriate revenues in all other non-initiative circumstances." Attorneys for the plaintiffs said, "We are disappointed in today’s ruling, but believe the Court of Appeals will disagree."

On July 22, 2021, the Missouri Supreme Court unanimously decided that the amendment was constitutional reversing Judge Beetem's ruling. The court said, "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 court concluded, "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)." This means the Department of Social Services and Missouri HealthNet, who are responsible for the administration of Medicaid in Missouri, must expend the funds appropriated by the state legislature for all Missouri individuals eligible for Medicaid under the amendment.

Text of measure

Ballot title

The ballot title for the measure was as follows:

“

Do you want to amend the Missouri Constitution to: adopt Medicaid Expansion for persons 19 to 64 years old with an income level at or below 133% of the federal poverty level, as outlined in the Affordable Care Act; prohibit placing greater or additional burdens on eligibility or enrollment standards, methodologies or practices on persons covered under Medicaid Expansion than on any other population eligible for Medicaid; and require state agencies to take all actions necessary to maximize federal financial participation in funding medical assistance under Medicaid Expansion? State government entities are estimated to have one-time costs of approximately $6.4 million and an unknown annual net fiscal impact by 2026 ranging from increased costs of at least $200 million to savings of $1 billion. Local governments expect costs to decrease by an unknown amount.

”

Ballot summary

The ballot summary for the measure was as follows:

“

A 'yes' vote will amend the Missouri Constitution to adopt Medicaid Expansion for persons 19 to 64 years old with an income level at or below 133% of the federal poverty level, as set forth in the Affordable Care Act. Currently, Medicaid eligibility is set forth in state statute, but this amendment adds Medicaid Expansion to our constitution. This amendment prohibits placing greater or additional burdens on eligibility or enrollment standards, methodologies or practices on persons covered under Medicaid Expansion than on any other population eligible for Medicaid. The amendment requires state agencies to take all actions necessary to maximize federal financial participation in funding medical assistance under Medicaid Expansion. Federal law requires states to fund a portion of the program in order to receive federal funding (state match). This amendment does not provide new state funding or specify existing funding sources for the required state match. A 'no' vote will not amend the Missouri Constitution to adopt Medicaid Expansion. If passed, this measure has no direct impact on taxes.

”

Constitutional changes

See also: Missouri Constitution

Amendment 2 added a new section—Section 36(c)—to the Article IV of the Missouri Constitution. The following underlined text was added: Note: Use your mouse to scroll over the below text to see the full text.

Section 36(c). 1. Notwithstanding any provision of law to the contrary, beginning July 1, 2021, individuals nineteen years of age or older and under sixty-five years of age who qualify for MO HealthNet services under 42 U.S.C. Section 1396a(a)(10)(A)(i)(VIII) and as set forth in 42 C.F.R. 435.119, and who have income at or below one hundred thirty-three percent of the federal poverty level plus five percent of the applicable family size as determined under 42 U.S.C. Section 1396a(c)(14) and as set forth in 42 C.F.R. 435.603, shall be eligible For medical assistance under MO HealthNet and shall receive coverage for the health benefits service package. 2. For purposes of this section "health benefits service package" shall mean benefits covered by the MO HealthNet program as determined by the department of social services to meet the benchmark or benchmark-equivalent coverage requirement under 42 U.S.C. Section 1396a(K)(1) and any implementing regulations. 3. No later than March 1 2021, the Department of Social Services and the MO HealthNct Division shall 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. 4. The Department of Social Services and the MO HealthNet Division shall take all actions necessary to maximize federal financial participation in funding medical assistance pursuant to this section. 5. No greater or additional burdens or restrictions on eligibility or enrollment standards, methodologies, or practices shall be imposed on persons eligible for MO HealthNet services pursuant to this section than on any other population eligible for medical assistance. 6. All references to federal or state statutes, regulations or rules in this section shall be to the version of those statutes, regulations or rules that existed on January 1, 2019.

Readability score

See also: Ballot measure readability scores, 2020

Using the Flesch-Kincaid Grade Level (FKGL and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The secretary of state wrote the ballot language for this measure. The FKGL for the ballot title is grade level 14, and the FRE is 22. The word count for the ballot title is 128, and the estimated reading time is 34 seconds. The FKGL for the ballot summary is grade level 15, and the FRE is 23. The word count for the ballot summary is 167, and the estimated reading time is 44 seconds.

Support

Yes on 2: Healthcare for Missouri led the campaign in support of Amendment 2.

Supporters

Officials

• Missouri State Representative Tommie Pierson Jr. (D)
• Former State Representative Raymond Weter (R)

Candidates

• Tishaura Jones (Nonpartisan) - State treasurer candidate

Corporations

• AARP MIssouri

Organizations

• American Cancer Society Cancer Action Network
• American Diabetes Association
• American Heart Association
• American Kidney Fund
• American Lung Association
• Cystic Fibrosis Foundation
• Health Forward Foundation
• Hemophilia Federation of America
• Leukemia & Lymphoma Society
• Missouri Academy of Family Physicians
• Missouri Chamber of Commerce
• Missouri Family Health Council
• Missouri NAACP State Conference
• Missouri Nurses Association
• National Hemophilia Foundation
• National Multiple Sclerosis Society
• National Organization for Rare Disorders
• Sixteen Thirty Fund
• Susan G. Komen for the Cure
• The Fairness Project
• Washington University in St. Louis

Arguments

• Christian County Commissioner and former Missouri State Representative Raymond Weter (R): "Medicaid expansion will bring more than $1 billion of our tax dollars back from Washington every year. That will help keep rural hospitals open, protect our jobs, and ensure all Missourians have access to health care no matter where they live."
• Missouri State Representative Tommie Pierson Jr. (D): "A yes vote on Amendment 2 will bring billions of Missouri tax dollars back into our state, closing a huge coverage gap so that 300,000 of our low-income neighbors, most of whom are working, will finally get health care that has long be denied. Let us fix this unequal and unjust system by passing Medicaid expansion in Missouri."
• Paula Baker, chief executive officer of Freeman Health System: "Medicaid expansion can help reduce high-cost emergency health interventions that could be managed with regular primary care, including access to rescue medications or chronic disease management. Avoiding unnecessary emergency department care will reduce costs for patients and the healthcare system, and increase the efficient use of health resources."
• Missouri Hospital Association President Herb Kuhn: "Hospital closures in rural communities have increased the distance to lifesaving care for Missourians suffering from traumatic injuries, stroke and heart attack. Minutes count in medical emergencies. Medicaid expansion will help maintain access to emergency care in rural Missouri — benefiting those gaining coverage and all rural residents."
• Paul Taylor, chief executive officer of OCH Health System: "The past few months have shown that access to care is more important than ever. It’s time to protect frontline health care jobs, help keep endangered rural hospitals open, and ensure that all Missourians have access to emergency care."

Campaign advertisements

The following video was released by Healthcare for Missouri on Vimeo:

Opposition

No on 2 in August led the campaign in opposition to Amendment 2.

Opponents

Officials

• Governor Mike Parson (R)
• Missouri State Senator David Sater (R)
• Missouri State Representative Elijah Haahr (R)
• Missouri State Representative Hannah Kelly (R)
• Missouri State Representative Don Mayhew (R)
• Missouri State Representative Suzie Pollock (R)
• Missouri State Representative Cody Smith (R)
• Missouri State Representative Curtis Trent (R)
• Missouri State Representative Sara Walsh (R)
• State treasurer Scott Fitzpatrick (R)
• Lieutenant governor Mike Kehoe (R)

Organizations

• Americans for Prosperity-Missouri
• Missouri Farm Bureau

Arguments

• Missouri Governor Mike Parson (R): "I don’t think it’s the time to be expanding anything in the state of Missouri right now. There’s absolutely not going to be any extra money whatsoever."
• Missouri Lieutenant Governor Mike Kehoe (R): "Medicaid expansion is financially unsupportable and unsustainable. In the short term, it will require cuts to education. In the long term, it will result in higher taxes for Missourians."
• Missouri House Speaker Elijah Haahr (R): "If you expand Medicaid in the state, a lot of medical providers in the state will simply limit or cap the number of Medicaid patients they see because their reimbursement rates are so low."
• Missouri Treasurer Scott Fitzpatrick (R): "We’ve had to cut over $500 million of spending from [the 2019] budget to essentially make room for growth in Medicaid. ... In a year where we are already cutting a lot of money out of higher education and other things in the state to pay for Medicaid growth, I don’t see us coming up with an extra $200 million."
• Ryan Johnson, a senior adviser for United for Missouri: "The myth of free federal money is just that. We're going to be on the hook for a significant amount of money; and if, and I agree it's an if, that money ever went away because of the federal deficit ... then Missouri would be constitutionally obligated to make up the entirety of the cost for expanding Medicaid."
• Don Hinkle, editor of The Pathway: "Amendment 2 is an expansion of Obamacare, another sneaky effort to expand taxpayer-funded abortions and bankrupt the state. This socialistic monstrosity is the latest example of “government creep,” the never-ending attempt by government to control our lives and rob us of our freedom."
• Blake Hurst, president of Missouri Farm Bureau: "Pouring more taxpayer dollars into Medicaid without fixing the problems that are bankrupting rural hospitals will only make a bad situation worse. We need to find solutions that make healthcare more accessible and affordable, not just expand government further."

Campaign advertisements

The following video was released by No on 2 in August on YouTube:

Title: "Vote No On 2 In August"

Campaign finance

The campaign finance information on this page reflects the most recently scheduled reports processed by Ballotpedia, which covered through September 3, 2020.

See also: Campaign finance requirements for Missouri ballot measures

There were two political action committees, Healthcare for Missouri and Missourians for Healthcare, registered to support Amendment 2. The committees raised $10.7 million, with Missourians for Healthcare receiving the bulk of the contributions.

There was one committee, No on 2 in August, registered in opposition to Amendment 2. The campaign reported $463,344.04 in contributions.

	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Support	$9,830,686.63	$928,282.13	$10,758,968.76	$9,600,484.99	$10,528,767.12
Oppose	$200.00	$463,144.04	$463,344.04	$58.90	$463,202.94

Support

The following committees were registered in support of the amendment:

Committees in support of Amendment 2
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Missourians for Healthcare	$9,826,001.13	$928,282.13	$10,754,283.26	$9,598,314.99	$10,526,597.12
Healthcare for Missouri	$4,685.50	$0.00	$4,685.50	$2,170.00	$2,170.00
Total	$9,830,686.63	$928,282.13	$10,758,968.76	$9,600,484.99	$10,528,767.12

Donors

The following is a list of the top donors to Missourians for Healthcare.

Donor	Cash Contributions	In-Kind Contributions	Total Contributions
North Fund	$2,555,000.00	$107,000.00	$2,662,000.00
Missouri Hospital Association	$2,102,187.39	$125,083.41	$2,227,270.80
Health Care Issues Committee of the Missouri Hospital Association	$1,650,000.00	$0.00	$1,650,000.00
Health Forward Foundation	$750,000.00	$0.00	$750,000.00
The Fairness Project	$200,000.00	$244,410.46	$444,410.46

Opposition

There was one committee, No on 2 in August, registered in opposition to Amendment 2.

Committees in opposition to Amendment 2
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
No on 2 in August	$200.00	$463,144.04	$463,344.04	$58.90	$463,202.94
Total	$200.00	$463,144.04	$463,344.04	$58.90	$463,202.94

Donors

The following is a list of the top donors to No on 2 in August.

Donor	Cash Contributions	In-Kind Contributions	Total Contributions
Cornerstone 1791	$0.00	$132,704.00	$132,704.00
Pelopidas	$0.00	$34,225.39	$34,225.39

Methodology

To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.

Media editorials

See also: 2020 ballot measure media endorsements

Ballotpedia identified the following media editorial boards as taking positions on the ballot measure. If you are aware of a media editorial board position that is not listed below, please email the editorial link to editor@ballotpedia.org.

Support

• St. Louis Dispatch Editorial Board: "Missouri’s Republican-controlled Legislature has refused for years to expand Medicaid as envisioned under the Affordable Care Act. Whatever excuses they’ve made, the crassly partisan reason has always been clear: They would rather let poor Missourians suffer needlessly, while refusing hundreds of millions of federal dollars, than to go along with former President Barack Obama’s signature policy. ... Republican Gov. Mike Parson late last month made that task considerably more difficult by moving the vote up to the low-turnout Aug. 4 primary instead of the November general election. Nothing would be more just than for voters to turn out in droves anyway and, finally, get this done."
• The Kansas City Star Editorial Board: "In the middle of an historic pandemic, it’s a moral imperative. Medicaid expansion should not be a partisan issue, and indeed, business groups, medical associations and religious organizations are backing the measure that will provide more families access to health care. ... Vote yes on Aug. 4 for Amendment 2."
• St. Louis Review Editorial Board: "Medicaid expansion, which is on the Aug. 4 ballot in Missouri, provides an opportunity to show that we are pro-life not just when a woman is pregnant, but we care for the mother after her child is born and we care for people throughout their lives. ... The light of the Gospel and the moral and social teaching of the Church as well as our own reason compel us to vote in favor of Amendment 2, Medicaid expansion."

Opposition

Ballotpedia had not identified media editorial boards in opposition to the ballot measure.

Background

Medicaid in Missouri

History

The Missouri HealthNet Division is a division of the Department of Social Services and the agency responsible for administering Medicaid. The Missouri Medicaid program was established by the Missouri General Assembly in October 1967. In fiscal year 2019, Missouri appropriated $10.5 billion to the Medicaid program. This included $5.8 billion of federal funding for the state program. As of October 2019, 15 percent of Missouri's population was covered by Medicaid.

The first time the state considered expanding Medicaid was in 2017 when the Missouri General Assembly introduced Senate Bill 70 (SB 70) and Senate Bill 28 (SB 28). SB 70 would have also expanded eligibility to include adults with income up to 138 percent of the poverty level. SB 28 would have allowed the state to receive Medicaid funds under a block grant. Both did not advance in the legislative session. In 2018, the state Senate considered Senate Bill 713, but the bill did not make it out of committee. It would have also expanded eligibility to include adults with income up to 138 percent of the poverty level. In 2020, the state legislature considered Senate Bill 564 and Senate Bill 603, but neither made it out of committee.

Eligibility

The following populations were eligible for Medicaid at the time of the election in Missouri:

• Over 65 years of age,
• Blind or disabled,
• Adults with dependent children with a household income at or below 22 percent of the federal poverty level,
• Infants under the age of one in a household with an income at or below 196 percent of the federal poverty level,
• Children between the ages of one to 18 in a household with an income at or below 150 percent of the federal poverty level, and
• Pregnant women with a household income at or below 196 percent of the federal poverty level.

At the time of the election, Missouri did not have a work requirement for Medicaid eligibility. As of October 2019, 58 percent of adult Medicaid enrollees were working.

Medicaid expansion under the ACA

See also: Medicaid and Obamacare

The Affordable Care Act (ACA), also known as Obamacare, was signed into law on March 23, 2010. The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level, which amounted to $16,394 for individuals and $33,534 for a family of four in 2016. The law was designed to provide 100 percent of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states. By January 1, 2017, 19 states, including Utah, had chosen not to expand eligibility.

From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.

The Affordable Care Act had not provided tax credits to adults with household incomes less than the federal poverty line because the law had aimed to cover these people under Medicaid. In states that did not expand Medicaid, many of these adults fell into a coverage gap in which they neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of 2016, around 2.6 million people fell into this coverage gap across the 19 states that did not expand Medicaid.

Adoption of Medicaid expansion under the ACA

As of January 2022, a total of 38 states and Washington, D.C., had expanded or voted to expand Medicaid, while 12 states had not. The map below provides information on Medicaid expansions by state; for states that expanded, hover over the state to view the political affiliation of the governor at the time of expansion.

Medicaid expansion on the ballot

2020

On August 4, 2020, Missouri voters approved an initiated constitutional amendment to expand Medicaid with 53.3% of the vote. Voters in Oklahoma approved Oklahoma State Question 802 on June 30, 2020, in a vote of 50.5% in favor to 49.5% opposed. Oklahoma State Question 802 and Missouri Amendment 2 were designed to expand Medicaid eligibility to adults between 18 and 65 whose income is 133% of the federal poverty level or below, effectively expanding Medicaid to those with incomes at or below 138% of the federal poverty level under the Affordable Care Act.

2018

In November 2018, voters in Idaho, Montana, Nebraska, and Utah decided ballot initiatives concerning Medicaid expansion and the funding of expanded Medicaid coverage. In January, voters in Oregon approved Measure 101, thereby upholding 2017 legislation to provide funding for the state's portion of costs for expanded Medicaid coverage through a tax on healthcare insurance and the revenue of certain hospitals.

2018 measures:

Measure	Description	Status
Idaho Proposition 2	Expand coverage to 138 percent of the federal poverty line
Montana I-185	Extend expanded coverage and increase tobacco taxes	d
Nebraska Initiative 427	Expand coverage to 138 percent of the federal poverty line	a
Utah Proposition 3	Expand to 138 percent of the federal poverty line and increase sales tax
Oregon Measure 101	Upheld health insurance tax to fund expanded coverage	a

2017

In 2017, voters in Maine approved Question 2 to expand Medicaid to persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line. The measure was the first citizen initiative to implement an optional provision of Obamacare.

Path to the ballot

See also: Laws governing the initiative process in Missouri

Process in Missouri

In Missouri, the number of signatures required to qualify an initiated constitutional amendment for the ballot is equal to 8 percent of the votes cast for governor in the previous gubernatorial election in six of the eight state congressional districts. Signatures must be filed with the secretary of state six months prior to the election.

The requirements to get an initiated constitutional amendment certified for the 2020 ballot:

• Signatures: The smallest possible requirement was 160,199 valid signatures. The actual requirement depends on the congressional districts in which signatures were collected.
• Deadline: The deadline to submit signatures was May 3, 2020.

Once the signatures have been filed with the secretary of state, the secretary copies the petition sheets and transmits them to county election authorities for verification. The secretary of state may choose whether the signatures are to be verified by a 5 percent random sample or full verification. If the random sampling projects between 90 percent and 110 percent of required signatures, a full check of all signatures is required. If more than 110 percent, the initiative is certified, and, if less than 90 percent, the initiative fails.

Stages of this initiative

Heidi Miller, a physician based in St. Louis, Missouri, filed two versions of the ballot initiative. The first version—Initiative 2020-053—was a statute. The second version—Initiative 2020-063—was a constitutional amendment. The campaign Healthcare for Missouri decided to collect signatures for Initiative 2020-063, the constitutional amendment. On June 13, 2019, Secretary of State Jay Ashcroft (R) approved the initiative for signature gathering.

On September 4, 2019, Miller announced that Healthcare for Missouri would seek to place the initiative before voters in 2020. She said, "I feel so strongly that hardworking Missourians across the state deserve affordable healthcare so that they don’t have to decide between their medications and putting food on the table."

In an email to supporters on March 23, 2020, Healthcare for Missouri wrote, "Thanks to a strong and early start to voter signature collections, we will be able to submit the required number of valid signatures by the early May deadline."

Healthcare for Missouri submitted 341,440 signatures to the Missouri Secretary of State on May 1, 2020.

On May 22, 2020, the Missouri Secretary of State issued a statement certifying the initiative for the ballot. The secretary of state used a random sample method, which projected enough valid signatures in congressional districts 1, 2, 3, 5, 6, and 7 to qualify the measure for the ballot. On May 26, the governor called for the measure to be put on the August 4 primary election ballot. May 26 was the deadline for the governor to put the measure on an earlier ballot instead of the November general election. A total of 269,118 signatures were projected to be valid by the random sampling from within all eight congressional districts, which means there was an average validity rate of 78.8%.

In districts 1, 2, 3, 5, 6, and 7, a total of 172,015 valid signatures were required. Within those districts, a projected total of 258,686 signatures were valid.

On May 26, 2020, Governor Mike Parson (R) announced that the initiative would appear on the August 4 primary ballot.

Cost of signature collection:
Sponsors of the measure hired MOVE Action and FieldWorks LLC to collect signatures for the petition to qualify this measure for the ballot. A total of $207,880.00 was spent to collect the 160,199 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $1.30.

Lawsuit

Lawsuits overview
First lawsuit
Issue: Whether the initiative violates the Missouri Constitution
Court: Missouri 19th Judicial Circuit Court
Ruling: Ruled in favor of defendants, allowing a vote on the measure
Plaintiff(s): Americans for Prosperity-Missouri	Defendant(s): Missouri Secretary of State Jay Ashcroft (R)
Plaintiff argument: The initiative violates the Missouri Constitution because it does not create a new revenue source to fund Medicaid expansion in the state.	Defendant argument: The initiative does not violate the Missouri Constitution because it does not require the legislature to appropriate funds and therefore does not need to include a new revenue source.
Second lawsuit
Issue: Whether the initiative violates the Missouri Constitution
Court: Missouri 19th Judicial Circuit Court
Ruling: Ruled in favor of defendants, allowing a vote on the measure
Plaintiff(s): United for Missouri	Defendant(s): Missouri Secretary of State Jay Ashcroft (R)
Plaintiff arguments: The initiative violates the Missouri Constitution because it does not create a new revenue source to fund Medicaid expansion in the state.	Defendant arguments: The initiative does not violate the Missouri Constitution because it does not require the legislature to appropriate funds and therefore does not need to include a new revenue source.

  Sources: Missourinet and CT Post

On May 26, 2020, Americans for Prosperity-Missouri (AFP-MO) filed a lawsuit against the Missouri Secretary of State Jay Ashcroft (R) that argued the initiative violates the Missouri Constitution because, according to the lawsuit, it proposes appropriating state funds without creating a new source of revenue. AFP-MO State Director Jeremy Cady said, "This lawsuit is intended to protect the ballot initiative process. This ballot initiative violates the Missouri Constitution by mandating the state fund the expansion of Medicaid without providing a funding source. This mandate will divert critical funds from our children’s education or force the state to increase taxes. At a time when our state is already in dire economic straits, we should not tie the hands of the legislature with this unconstitutional ballot initiative."

On May 27, 2020, United for Missouri filed a similar lawsuit against the Missouri Secretary of State Jay Ashcroft (R). Ryan Johnson, a senior advisor to United for Missouri and the owner of Exemplar Public Affairs, argued, "The Missouri Constitution very clearly requires an initiative petition to identify a revenue source to fund the objectives of the initiative. Initiative Petition 2020-063 expands access to Medicaid with a staggering estimated cost of $2 billion annually and does not address how to fully pay for it. This initiative, as certified by Secretary of State Ashcroft, is unconstitutional on its face because it seeks to create what amounts to an unfunded liability in the Constitution."

Healthcare for Missouri responded to the lawsuits saying, "The Missouri state auditor has also issued a report acknowledging that Medicaid expansion could save the state up to $1 billion dollars a year, given the 900 percent return on investment that Medicaid expansion would deliver to the state. ... With Amendment 2, the state will benefit from a much better federal matching rate for those already provided services, resulting in significant savings."

On June 2, 2020, Cole County Circuit Judge Daniel Green ruled in favor of Healthcare for Missouri allowing the measure to appear on the ballot. Judge Green argued that the ballot measure does not require the state legislature to appropriate money for Medicaid expansion, and therefore, it does not need to provide a funding source.

On June 8, 2020, Missouri Western District Court of Appeals upheld Judge Green's decision to keep the initiative on the August ballot after United for Missouri and Americans for Prosperity-Missouri appealed it. Presiding Judge Mark Pfeiffer said, "The proposed measure does not direct or restrict the General Assembly’s ability to change the amount of appropriations for the MO HealthNet program or to increase or decrease funding for the program based on health-care-related costs."

How to cast a vote

See also: Voting in Missouri

Click "Show" to learn more about voter registration, identification requirements, and poll times in Missouri.

How to cast a vote in Missouri

The information below covers regular voting policies in the state. Information may have not applied to the election on November 3, 2020, because of temporary changes in response to coronavirus. Click here to read about changes made for the 2020 elections. Poll times In Missouri, all polling places are open from 6:00 a.m. to 7:00 p.m. Central Time. An individual who is in line at the time polls close must be allowed to vote. Registration Check your voter registration status here. To vote in Missouri, one must be 18 years old, a United States citizen, and Missouri resident. An applicant may print an application, pick one up from a county clerk's office, or request that an application be mailed. The completed application must be returned by mail. All returned applications must be postmarked at least 27 days prior to Election Day in order to be processed. An applicant may also register to vote online. Automatic registration Missouri does not practice automatic voter registration. Online registration See also: Online voter registration Missouri has implemented an online voter registration system. Residents can register to vote by visiting this website. Same-day registration Missouri does not allow same-day voter registration. Residency requirements To register to vote in Missouri, you must be a resident of the state. State law does not specify a length of time for which you must have been a resident to be eligible. Voters may file change-of-address forms after the registration deadline, up to and including Election Day, provided that they can present photo identification upon doing so. Verification of citizenship See also: Laws permitting noncitizens to vote in the United States Missouri requires those registering to vote by mail for the first time to provide a form of identification that shows proof of United States citizenship. Verifying your registration The Missouri Secretary of State's office allows residents to check their voter registration status online. Voter ID requirements Missouri requires voters to present photo identification while voting. The following were accepted forms of identification as of April 2023. Click here for the Missouri Secretary of State's page on accepted ID to ensure you have the most current information. Voters can present the following forms of information: A nonexpired Missouri driver or non-driver license; A nonexpired military ID, including a veteran’s ID card; A nonexpired United States passport; or Another photo ID issued by the United States or the state of Missouri which is either not expired or expired after the date of the most recent general election. If a voter does not have an ID, he or she can obtain one for free by filling out this form.

See also

2020 measures

• 2020 ballot measures
• Healthcare on the ballot
• 2020 legislative sessions

Missouri

• Missouri ballot measures
• Missouri ballot measure laws
• Medicaid

News and analysis

• Ballot measure lawsuits
• Ballot measure readability
• Ballot measure polls

External links

• Initiative full text

Support

• Yes on 2 campaign website
• Yes on 2 Facebook page
• Yes on 2 Twitter page

Opposition

• No on 2 in August campaign website
• No on 2 in August Facebook page