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Columbia Missourian

VOTERS GUIDE: Proposition E

By Nuria Mathog
October 31, 2012 | 3:59 p.m. CDT

Missouri voters will be asked Nov. 6 whether to change state law to prohibit the creation of a state health insurance exchange.

Ballot language: Shall Missouri Law be amended to prohibit the governor or any state agency, from establishing or operating state-based health insurance exchanges unless authorized by a vote of the people or by the legislature?


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No direct costs or savings for state and local governmental entities are expected from this proposal. Indirect costs or savings related to enforcement actions, missed federal funding, avoided implementation costs, and other issues are unknown.

What does this mean? Proposition E would amend Missouri law to prevent the governor or a state agency from establishing a state health insurance exchange without voter or legislative approval.

What is a health insurance exchange? A health insurance exchange is an online market that allows small businesses and individuals to compare the prices, services, benefits and quality of different health insurance plans.  

Under the individual mandate provision of the federal Patient Protection and Affordable Care Act, which is scheduled to take effect in 2014, Americans will be required to buy health insurance or pay a fine. Exchanges are designed to provide affordable insurance plans by creating a large pool of buyers and encouraging private insurers to set competitive rates.

The Affordable Care Act requires states to establish a health insurance exchange by Jan. 1, 2014. If a state fails to do so, the federal government will operate an exchange for it. Exchanges must be government or nonprofit agencies, and states can collaborate to create regional exchanges. Additionally, states will have the option of creating multiple exchanges, as long as there is no overlap among different geographical areas.

To create a state health insurance exchange, Missouri must submit an application and a declaration signed by Gov. Jay Nixon to the U.S. Department of Health and Human Services by Nov. 16.

What does Proposition E entail? Proposition E was placed on the ballot when the General Assembly approved Senate Bill 464, which was cosponsored by state Sens. Rob Schaaf and Frank Ruff.

If voters approve the proposition, Nixon would be prohibited from establishing a state health exchange through an executive order, while state agencies would likewise be forbidden from acting unilaterally.

Additionally, Missouri residents and the General Assembly would have legal standing to sue the state if an exchange is created without voter or legislative consent.

What do supporters and opponents say? Proponents of Proposition E argue that competition should be left to the free market and that the government should not have the authority to implement an exchange without the approval of voters or legislators. They also argue that a state insurance exchange could end up proving more costly to insurance buyers.

Opponents argue that Missouri is obligated under federal law to establish a state insurance exchange and are concerned that Missouri could lose federal money designed to implement and operate such an exchange. Additionally, they say the creation of a state insurance exchange would allow more Missouri residents to afford health insurance.

What are other states' policies? Massachusetts and Utah both established health insurance exchanges several years before the Affordable Care Act was approved. According to the National Conference of State Legislatures, after the federal law went into effect, 10 states and Washington, D.C., passed legislation creating exchanges, and four other states — Indiana, Kentucky, New York and Rhode Island — established exchanges through executive orders. Legislation is pending in an additional four states.

Twenty-one states have either failed to pass exchange-related legislation or have taken no legislative action, while nine states have determined that they will not be creating state health insurance exchanges.

Supervising editor is Scott Swafford.