2020 Missouri Amendment 2

The Affordable Care Act, 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 funding from states which did not wish to opt in.[3] In 2018, the Fairness Project supported successful ballot initiatives to expand Medicaid in conservative states such as Nebraska, Utah, and Idaho, where Republican leaders were unwilling to. 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 gained 346,000 signatures, Governor Mike Parson scheduled the initiative to appear on the August primary ballot.[6] United for Missouri and the Missouri branch of Americans for Prosperity filed lawsuits to prevent the expansion from appearing on the ballot, arguing the initiative violated a constitutional requirement to cite a funding source in ballot initiatives. The Cole County Circuit Court ruled in favor of the proposal, stating the initiative itself does not fund anything.[6][7] They 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 would 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 Obamacare, a law unpopular in the state, and some campaign material did not refer to a "Medicaid expansion".[5] Instead, supporters noted the federal funding the state's rural hospitals would receive as a result of the proposal's passage and stated it would prevent more hospitals from closing, as 15 in the state 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. The initiative was opposed by state Republican politicians such as Governor Mike Parson, who stated 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] Other conservatives and opponents said that at the time, Medicaid had taken up 40 percent of the state 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 illegal immigrants would come to the state looking for Medicaid coverage, despite them not being elgible 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 stated 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.[6][9]

The measure was approved with 53% of the vote. Support was most heavily concentrated in urban areas such as Columbia, Kansas City, St. Louis, and Springfield while conservative, rural areas voted against the measure, including in counties with large numbers of uninsured residents.[5] It has been cited as an example of the popularity of Medicaid expansion, 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

In 2021, Governor Parson claimed the state legislature refused to fund the expansion in that year's state budget so it would not be implemented by the July 1 deadline.[10][11] 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 in a 7–0 decision.[11][12]

Enrollment in the Medicaid expansion began in October 2021, with Missouri becoming the 38th state to opt into the Medicaid expansion.[13] Implementation was slow, with only 7% of newly eligible Missourians enrolling in the expansion's first month, compared to about half in Idaho and Montana. The state's outreach efforts regarding the expansion had been much slower than in other states such as Oklahoma.[14] In early 2022, the state found it was taking 70 days to process an average Medicaid application, even though federal law mandated wait times be under 45 days.[15]

In 2022, state 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 are unsustainable.[16][17] However, after a Supreme Court decision which seemed to prevent the state from being allowed to enforce a work requirement, Republicans gave up on the proposed amendment.[18]

• 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