Voters in deep-red Missouri narrowly approved Medicaid expansion on Tuesday over the objections of Republican state leaders.
The vote makes Missouri the 38th state to expand Medicaid under the Affordable Care Act, and the sixth state in three years to pass it by ballot measure, a blow to the Trump administration's anti-ObamaCare agenda.
The 12 remaining states are nearly all Republican-controlled.
The ballot measure was backed by progressive activists as well as state business and health groups; hospitals contributed more than $10 million to the campaign.
The measure will expand the state's MO HealthNet program to anyone earning less than 133 percent of the poverty level, which is less than $18,000 a year for an individual, and less than $30,000 for a family of three.
The expansion will take effect on July 1, 2021.
The measure was approved 53 percent to 46 percent, with just about 99 percent of precincts reporting.
According to Healthcare for Missouri, one of the groups spearheading the effort, it would mean coverage for more than 200,000 currently uninsured Missourians, and could result in up to $1 billion of savings.
Missouri has one of the strictest Medicaid programs in the country. As the policy stands currently, adults who do not have disabilities and who do not have minor children living at home cannot qualify for Medicaid coverage, no matter how little money they make. Parents with dependent children can only earn up to 21 percent of the poverty level, which is about $2,700 each.
Under ObamaCare, the federal government will pay 90 percent of the cost of states that expand Medicaid. Missouri has not yet outlined a plan to pay for its 10 percent share.
The state is solidly conservative, as President TrumpDonald TrumpUN meeting with US, France canceled over scheduling issue Trump sues NYT, Mary Trump over story on tax history McConnell, Shelby offer government funding bill without debt ceiling MORE won 57 percent of the vote there in 2016. Republicans, who have supermajorities in both the state House and Senate, were opposed to the measure, as was Gov. Mike Parson (R), who is up for reelection.
Parson argued the state would not be able to afford the cost of expansion on top of the fiscal strain of the coronavirus pandemic. He and other opponents argued Medicaid expansion would mean less funding for education and other programs.
While Republican leaders in other expansion states were able to slow-walk expansion implementation, the language used in Missouri's ballot measure ensures that Medicaid expansion is enshrined in the state's constitution, which would make it extremely difficult for Parson or the legislature to dismantle it in the future or add any conservative policies, like work requirements.
Missouri is now the second state to expand Medicaid during the pandemic, following Oklahoma's vote in July.
"Politicians who fail to heed the voters’ message on health care are going to be in trouble this November. Two red states, that Trump won by double digits in 2016, just sent the largest possible rebuke to the President’s attacks on the Affordable Care Act,” said Jonathan Schleifer, executive director of The Fairness Project, the nonprofit group that has spearheaded every Medicaid expansion ballot measure to date.
Stakeholders, meanwhile, said that they think the pandemic has helped people realize the benefit of expanded health coverage.
"Before the pandemic and the resultant tanking economy, expansion votes in Missouri and Oklahoma, and the other four states might have had a different outcome," said Jerry Vitti, the CEO of Healthcare Financial Inc., a company the helps connect low-income people with government-sponsored programs.
"But now people, even those in red states, are very concerned about their physical health and that of their families," Vitti said.
Updated at 9:12 a.m.