Missouri residents, tired of inaction on their proposal to expand Medicaid to cover more of the state’s poorer residents decided to take the issue into their own hands. They drafted petitions and gathered enough signatures to bring the issue to the ballot, where the citizens’ true desire will be heard.

If the initiative passes, an estimated 300,000 low-income Missouri residents will be eligible for the popular Federal health insurance program. Under 2020 poverty guidelines, expanded Medicaid coverage would provide health insurance to a single adult making less than $17,608 annually, or adults in a family of four making less than $36,156 annually.

Missouri is one of just six states controlled by Republicans, who have gone around their legislatures to bring the issue of expanding Medicaid to a vote of the people. So far, Idaho, Maine, Nebraska, Utah, and most recently Oklahoma have all expanded Medicaid through ballot questions. Will Missouri be the sixth?

“It’s a movement that builds with every election,” Jonathan Schleifer, executive director of the Fairness Project told healthcare reporters on a call following Oklahoma’s successful “Yes on 802” campaign that is putting Medicaid expansion into that state’s constitution.

The Fairness Project has helped put together all five of the successful Medicaid expansion campaigns in Republican-leaning states. They’re also involved in the Missouri initiative election on Aug. 4.

While the Fairness Project is batting 100%, they barely pulled out a victory in Oklahoma. The issue passed by less than a one percent margin. Of Oklahoma’s 77 counties, only 7 counties voted to pass the ballot issue. All of those counties were in and surrounding the state’s two largest metropolitan areas, Tulsa and Oklahoma City.

The ballot issue certainly did become a battle between the rural and urban voters and a similar breakdown could likely be expected in Missouri, with St. Louis and Kansas City, the state’s progressive and Democratic centers expected to favor expansion.


Despite the Fairness Projects series of successes, a victory in Missouri is far from guaranteed. Among the challenges is the placement of the issue on the August primary ballot, versus the November general election. Primary turnout is typically low, and it’s even lower for Democrats, who typically support Medicaid expansion.

However, unlike Republicans, Democrats have few hot primary races and may be challenged to generate enough voter turnout to squeak out a victory.


A new Missouri law expanded the state’s individuals eligible to vote absentee to includes those who are in an at-risk category for contracting or transmitting COVID-19, including anyone age 65 or older.

This was a positive move, but falls way short of absentee voting laws in most states. Two-thirds of all states offer no-excuse absentee voting and five states conduct voting exclusively by mail. Oklahoma is one of the states that offer no-excuse absentee voting. There, more than 70,000 individuals voted absentee or early. Of those 75% supported the expansion amendment. If Oklahoma is model of success for Missouri, limited absentee voting may prove challenging in the Missouri election.


The budgets of states have been strained by a reduction of income and an increase in expenses associated with the COVID-19 pandemic. While the Federal government will pay 90% of the cost of Medicaid expansion, in tight budget times, Missouri Gov. Parson has said now is not the time to add the extra 10% share of Medicaid expansion to the state’s budget.

Tight budget concerns may help move some voters who are straddling the fence on the issue, to the side of no expansion.

Still, Missouri’s business community is supporting the expansion effort and are spouting the economic benefits of Medicaid expansion. A report commissioned by the Missouri Foundation for Health found Medicaid expansion would result in an annual job growth of 16,330 new jobs each year across the state and an average $2.5 billion increase in economic output.

Even with that level of economic growth, plus the additional benefit of health care for some of Missouri’s most vulnerable citizens, a positive vote on Medicaid expansion is not a sure thing for Missouri.

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