After years of Republican opposition, Missouri on Tuesday became the 38th state to expand Medicaid as voters approved Constitutional Amendment 2.

As of 1 a.m. Wednesday, 671,386 people — or 53.3% — voted “yes” on Amendment 2, according to the Secretary of State website. Only 24 of the state’s 3,575 precincts had not been counted at that time.

Voters in Boone County voted in favor of expansion by a large margin. With all 49 precincts reporting , 23,697 — or 67% — voted “yes,” according to the county clerk’s website.

Only seven of Missouri’s 114 counties approved Medicaid expansion. In addition to Boone, they included Greene (Springfield), Clay and Jackson (Kansas City suburbs), Platte, St. Charles (a St. Louis suburb) and St. Louis County. The city of St. Louis, which isn’t a county, also approved.

“Access to health care has never been more important than it is right now. Today’s historic victory for Amendment 2 highlights that when it comes to the care of our neighbors and the health of our ailing economy, Medicaid expansion uniquely unites Missourians,” A.J. Bockelman, the campaign manager for Yes on 2: Healthcare for Missouri, said in a statement.

Medicaid will now expand under the provisions of the 2010 Affordable Care Act. The expansion is expected to offer health care to as many as 230,000 Missourians between the ages 19 and 65 and create over 16,000 jobs.

When implemented, 90% of the health care coverage for new Medicaid enrollees under expansion are paid for by the federal government. Amendment 2’s fiscal note created by the state auditor predicts that, if passed by voters, it would cost $2 billion per year between the state and federal government. Missouri’s 10% responsibility would be an additional $200 million.

Medicaid expansion has been a key issue among Missouri’s lawmakers as well — particularly in the state race for governor. During a virtual election night rally, State Auditor Nicole Galloway, who won the Democratic nomination for governor Tuesday night, said she would implement expansion at no cost to Missouri taxpayers.

“I’ve said all along that Medicaid expansion brings billions to Missouri — the best economic development deal we’ve ever seen — and that we can expand health care without raising taxes or cutting other programs,” Galloway said.

After years of Republican opposition in the state legislature, supporters of Medicaid expansion turned in nearly twice as many petition signatures in May to place the initiative on the ballot. Shortly afterward, Gov. Mike Parson, who has been against Medicaid expansion, announced that the initiative would appear on Tuesday’s primary elections so the state could sooner understand its financial situation moving forward during the COVID-19 pandemic.

Prior to Tuesday’s vote, Medicaid costs to the state represented $2.5 billion in fiscal year 2021, about 25% of the state’s general revenue budget.

The issue appeared on the ballot alongside nominees for state, county and congressional offices. Medicaid expansion itself drew many voters to the ballot boxes Tuesday, according to those who spoke with Missourian reporters.

“I think (Medicaid expansion) is a great option for us and should be good for revenue for hospitals, so they are not always getting the bailouts,” said Brandon Blalock, 25, while voting at Unitarian Universalist Church of Columbia. “People can actually seek health care when they necessarily couldn’t afford it otherwise. I know some people don’t go to the doctor because they don’t have any money.”

Missouri’s Medicaid program currently does not offer health care to most adults without children and has a low-income eligibility threshold for parents, a group known as the healthcare coverage gap. When expansion is fully implemented, the program will offer coverage to Missourians earning up to 138% of the federal poverty level, about $18,000 for single adults or $30,000 for a family of three.

Because Medicaid expansion was on the ballot as a constitutional amendment, lawmakers are not able to make changes to the provision unless they are approved by voters in the future.

Voter Jefferson Daubitz, 21, said he was concerned about how the initiative was presented.

“I support this idea, but I am personally not for constitutionally mandating Medicaid expansion,” Daubitz said. “I understand the idea behind expanding it, but I don’t think that it should be written into the Constitution. You are not able to go in there to change the budget if you run out of money. We don’t have $200 million to do this right now.”

The cost of Medicaid expansion has troubled others who oppose it as well.

Opponents of Medicaid expansion have repeatedly said the only way the state can afford to pay for new enrollees is by shifting money from other resources, such as education or public safety.

Missouri State Treasurer Scott Fitzpatrick agreed. He said the General Assembly wouldn’t want to raise taxes to pay for the program, and money would likely need to be shifted from elsewhere.

“The only other area really large enough that you can go to and really cut a good chunk of money is education,” Fitzpatrick said.

However, evidence from other states shows that states with expanded Medicaid programs have actually saved money through less uncompensated care, more jobs, increased economic activity and other measures.

A fiscal analysis by the Center for Health Economics and Policy at Washington University in St. Louis predicted expansion would save the state up to $39 million after implementation costs.

Supporters also said the additional funds would stabilize the state’s struggling rural hospitals and clinics.

Several organizations praised Missourians for approving the ballot initiative. Throughout its campaign, Medicaid expansion received support from organizations such as the American Heart Association, the Missouri Hospital Association and the Missouri Chamber of Commerce.

“This is a victory for all Missourians, but especially those hardworking, yet low-income individuals caught in the coverage gap. However, today’s affirmation of Medicaid expansion by voters, marks a beginning rather than an end,” said Herb Kuhn, president and CEO of the Missouri Hospital Association.

  • Assistant city editor for the public health and safety beat. I am a second year graduate student studying public policy journalism. You can reach me at mne275@umsystem.edu or on Twitter @MikaylaEasley

  • As senior editor of the Missourian, Fred Anklam manages general assignment reporters. He can be reached at anklamf@missouri.edu or in the newsroom at 573-882-5720.

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