For the seventh time in three years, voters will have an opportunity to provide health coverage to poor adults whom Republican leaders have failed to serve as Missourans decide whether to amend the states Constitution to guarantee access to Medicaid on Aug. 4.

The proposed change, backed by progressive activists and business groups, would expand MO HealthNet, as Medicaid is called in the state, to anyone earning less than 133% of the federal poverty level , which is about $17,000 a year for a single person. This Medicaid expansion is made possible by the 2010 Affordable Care Act , which provides 90% federal funding to cover the newly eligible people. If the Show-Me State approves, it would be the sixth to do so via popular ballot.

As many as 458,000 adult Missourians could qualify for Medicaid coverage under the expansion, including 190,000 who are currently uninsured, according to an analysis by Washington University in St. Louis.

The remainder would be low-income people who are now paying for private insurance either through an employer or the Affordable Care Acts health insurance exchange marketplace. Washington University also projects that Medicaid expansion would allow the state to spend less on other state health care programs, resulting in an overall savings.

Theyve waited more than long enough, and were still not seeing any indication that our legislature wants to do it, so were taking it to the people, said Jen Bersdale, executive director of Missouri Health Care for All in St. Louis. Its unfortunate that we have elected leaders who are trying to portray a false choice between health care for hardworking families and other priorities, especially a legislature that continues to push through tax cuts.

Missouri Is Trump Country

Missouri is a conservative state with a Republican governor and GOP control of the state legislature and opposed to Medicaid expansion. In addition , six of its eight representatives to the U.S. House are Republicans, as are both of its U.S. senators. And President Donald Trump soundly defeated Democratic presidential nominee Hillary Clinton in 2016 with 57% of the vote.

Those are obstacles supporters of Medicaid expansion must overcome, as are the challenges of winning on a progressive issue on a primary election day thats likely to attract more Republicans to the polls than Democrats and amid the novel coronavirus pandemic . Missourians have limited access to vote-by-mail.

Nevertheless, the Medicaid expansion ballot initiative has a real chance at passing, just as it did in Oklahoma and other conservative states, said Jake Haselswerdt , a political science professor at the University of Missouri in Columbia.

Haselswerdt noted that two years ago, Missouri voters passed initiatives to raise the minimum wage , make medical marijuana legal , reform congressional redistricting and repeal a right to work law that would have weakened labor unions. The Republican establishment opposed all of the measures

Theres also this recent history of Medicaid expansion passing in other red and purple states, he said. The people involved in both of those are involved in this. So the progressive community knows what its doing at this point.

Voters are not following the signals of politicians anymore on many, many issues, especially ones that are profoundly tied to their well-being and their neighbors well-being, and theyre willing to reject the dogma of the Republican Party and the ideology that has said we need to keep wages low and minimize the social safety net, said Jonathan Schleifer, executive director of the Fairness Project , a Washington-based organization that specializes in ballot initiatives for progressive policies like Medicaid expansion and minimum-wage increases.

The Fairness Project participated in the winning campaign to raise Missouris minimum wage. Americans actually agree on a lot of things when it comes to wages and health care and how they should be treated by their employers. But that is lost in politics, Schleifer said. They dont have to go begging for whats right from politicians. They can go have reasonable conversations with their neighbors about this policy and they can get what they like.

Red State Victories

Oklahoma voters approved a similar Medicaid measure earlier this month, following a successful ballot initiative in Maine in 2017 and the enactment of Medicaid expansion by voters in Idaho, Nebraska and Utah in 2018. An effort to keep Montanas Medicaid expansion in place failed two years ago, but Gov. Steve Bullock (D) signed legislation into law in 2019 to achieve the same result.

President Barack Obama and the congressional Democrats who authored the Medicaid expansion intended it to be nationwide, but a 2012 Supreme Court ruling made it optional for states. Missouri remains among the 13 states that have not adopted Medicaid expansion. Medicaid is jointly operated and financed by the federal government and the states.

The Supreme Court ruling sparked the expansion campaign, Bersdale said. Initially, even some Republican state legislators seemed open to a deal on Medicaid expansion, she said. That didnt last. We just started having more and more proverbial and literal doors shut in our face. Members of the majority party in Missouri just decided they werent going to talk about this issue.