2020 Missouri Amendment 2

The Affordable Care Act (ACA), passed in 2010, initially required states to expand Medicaid coverage to continue receiving federal Medicaid funding, but the Supreme Court ruled in National Federation of Independent Business v. Sebelius that it would be unconstitutional to remove Medicaid funding from states which did not wish to opt-in to the expansion.[3] In accordance with the decision, 18 states did not willingly expand Medicaid coverage under the ACA.[4]

In the late 2010s, the Fairness Project supported successful ballot initiatives to expand Medicaid where Republican leaders were unwilling to. In 2017, a Medicaid expansion initiative with their support succeeded in Maine. In 2018, the Fairness Project successfully supported similar referenda in conservative-leaning Nebraska, Utah, and Idaho. However, Nebraska and Utah added a work requirement despite such a requirement not being part of the ballot initiative.[4][5] Due to such resistance from Republican lawmakers, Medicaid expansion supporters began supporting constitutional amendment proposals to prevent similar restrictions from being implemented.[4] After a petition to put a Medicaid expansion initiative on the ballot in Missouri gained 346,000 signatures, Governor Mike Parson rescheduled the initiative to appear on the August primary ballot instead of on the November general election ballot.[6]

Conservative organizations United for Missouri and Americans for Prosperity's Missouri branch filed lawsuits to prevent the expansion from appearing on the ballot, arguing the initiative violated a constitutional requirement for ballot initiatives to cite a funding source when appropriating funds. The Cole County Circuit Court ruled in favor of the proposal, stating the initiative itself did not appropriate funds or change how the state legislature appropriates funds.[6][7] The organizations appealed the decision, additionally arguing that it violated a constitutional requirement that all petitions for ballot initiatives must contain the initiative's full text. On June 8, 2020, the Western District Missouri Court of Appeals unanimously upheld the lower court's ruling, allowing the initiative to remain on the ballot.[6][7]

The amendment appeared on the ballot as follows:[8]

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 set forth 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.

The deadline for the state to implement the specified Medicaid expansion was to be July 1, 2021.[6]

The initiative was campaigned for by YES on 2, which was supported by the Missouri Chamber of Commerce, the Missouri Hospital Association, the NAACP, the AARP, the AFL-CIO, and Catholic Charities of St. Louis, among others.[5] The YES on 2 campaign rarely mentioned the Affordable Care Act, a law unpopular in the state, and some campaign material did not refer to a "Medicaid expansion".[5] Instead, supporters noted the federal funding rural hospitals would receive as a result of the proposal's passage and stated it would prevent more hospitals from closing, as 15 in Missouri had done since 2014.[6][9] Supporters said most hospital closures were in states which did not opt into the Medicaid expansion.[6]

No on 2 in August campaigned against the initiative.[5] The initiative was opposed by Republican politicians such as Governor Mike Parson, who said that the state could not afford its share of the Medicaid expansion's cost.[9] Other groups opposing the initiative included Missouri Right to Life, the Missouri Farm Bureau, and Americans for Prosperity.[5] Missouri State House Budget Chair Cody Smith said that at the time, Medicaid had taken up 40% of Missouri's budget and noted that the state requires its budget to be balanced, so the cost of the expansion would need to come from other state programs such as education.[5][6] Prior to the vote, No on 2 in August mailed campaign material suggesting undocumented immigrants would come to Missouri looking for Medicaid coverage, despite them not being eligible for Medicaid.[5]

Democrats accused Governor Parson of scheduling the vote for the August primary elections instead of the higher-turnout general election to prevent the proposal from passing. Parson said he scheduled it in August to allow the state to understand, as soon as possible, whether it would need to account for extra spending in its budget assuming the initiative passes.[9]

The measure was approved with about 53% of the vote. Support was most heavily concentrated in urban areas such as Columbia, Kansas City, St. Louis, and Springfield, while conservative voters in rural areas voted against the measure, including in counties with large numbers of uninsured residents.[5] The amendment has been cited as an example of the popularity of expanding Medicaid, occurring weeks following the success of a similar ballot initiative in Oklahoma.[9]

Constitutional Amendment 2[1]

Choice	Votes	%
Yes	676,687	53.27
No	593,491	46.73
Total votes	1,270,178	100.00

The year following the measure's passage, lawmakers in the House Budget Committee voted against funding the expansion. Following the budget's passage, Governor Parson announced the state would be unable to expand its Medicaid program before the July 1 deadline.[10][11][12] The state was then sued for not complying with the results of the ballot initiative. The initiative itself was ruled unconstitutional by a Cole County Circuit Court judge before being appealed to the Missouri Supreme Court, which overturned the lower court's ruling and required the state to implement the expansion in a 7–0 decision.[12][13]

Enrollment in the Medicaid expansion began in October 2021, with Missouri becoming the 38th state to opt-in.[14] Implementation was slow, with only 7% of newly-eligible Missourians enrolling in the expansion's first month, compared to about 50% in Idaho and Montana. The state's outreach efforts regarding the expansion had been much slower than in other states such as Oklahoma.[15] The state was also slow at processing applications, taking an average of 70 days in early 2022, even though federal law mandated wait times be under 45 days.[16]

In 2022, Republican lawmakers proposed a constitutional amendment to allow the state legislature to decide how much it could fund the expansion and to implement a work requirement for it, claiming increases in the state's Medicaid budget following the passage of the initiative would be unsustainable.[17][18] After the United States Supreme Court refused to grant certiorari to other cases involving state healthcare programs with a work requirement, Republicans gave up on the proposed amendment.[19] The following year, Republican lawmakers proposed requiring that 60% of voters approve of any future state constitutional amendment to make it more difficult for them to pass.[20] As of May 2023, no similar amendment has passed in the Missouri Senate.[21]

• List of Missouri ballot measures
• 2020 Missouri elections

• YES on 2 (archived), which campaigned in favor of the initiative.
• No on 2 in August (archived), which campaigned against the initiative.
• 2020 Missouri Amendment 2 at Ballotpedia