Missouri voters approved an expansion of the state’s Medicaid program in Tuesday’s election, according to Vox’s partners at Decision Desk — making another success story at the ballot box for the program in a state where it had been stifled by Republican opposition.

The ballot initiative expands Medicaid eligibility to 138 percent of the federal poverty level (about $17,500 for an individual or $30,000 for a family of three) as authorized under the Affordable Care Act. An estimated 230,000 low-income Missourians will become eligible for Medicaid, though that number could end up being even higher given the recent job losses in the Covid-19 crisis. The federal government will cover 90 percent of the expansion costs; the state will be responsible for the other 10 percent.

The vote passed over the objections of Missouri’s Republican governor, Mike Parson, and conservative interest groups. Bills had been introduced in previous legislative sessions that would have expanded Medicaid, but they were ignored by the GOP majority.

This makes Missouri the 39th state to expand Medicaid through Obamacare; all the holdouts have been driven by GOP opposition to the 2010 health care law. About 2.3 million people nationwide are estimated to be uninsured because their state has refused to extend Medicaid eligibility and they make too little money to qualify for tax subsidies to buy private coverage. (Eligibility for the ACA subsidies starts at 100 percent of the poverty level.)

Medicaid expansion has been making inroads in Republican-led states through ballot initiatives in recent years. In 2017, Maine voters approved Medicaid expansion after years of opposition by then-Gov. Paul LePage. Voters in Idaho, Nebraska, and Utah okayed Medicaid expansion in 2018. Most recently, in June 2020, Oklahoma voters signed off on expansion in a ballot initiative.

Republican officials have sometimes tried to undo the results at the ballot box — in Utah, for example, GOP lawmakers sought to add restrictions on eligibility — but the Missouri initiative was specifically written to prevent tampering by the state legislature or the governor. Medicaid expansion would be written into the state constitution, and the state cannot introduce work requirements or any other limits on benefits.

Conservative groups had sued to try to stop the Medicaid expansion initiative from appearing on the ballot, arguing it violated the Missouri Constitution, but the language was upheld by state courts. Republicans argued that the state could not afford the expansion, in spite of the 90 percent federal funding match.

Supporters, on the other hand, said that expanding Medicaid and accepting the federal money would help prevent hospital closures as well as providing health insurance to many more Missourians. As Vox has previously reported, one in four rural hospitals nationwide are in danger of closing, and one of the strongest indicators of a hospital’s vulnerability is being located in a non-expansion state.

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