Missouri voters approved Medicaid expansion on Tuesday, but the measure was rejected by majorities of voters in every rural county in the state, including areas that have high rates of poverty and high uninsured rates.
In the wake of the election, some critics say that rural residents nearly derailed a Medicaid expansion campaign years in the making — but others say rural voters tipped the balance in its favor.
Though the margin of victory was 53.25% to 46.75%, it won a majority of votes in only eight mostly urban counties.
Commenting on the election results on social media, some observers said Missourians in conservative rural counties had voted “against their own interests.”
But expansion campaign organizer Genevieve Williams, who lives in Joplin, says there is much more happening in these communities than outsiders realize.
“Looking at it from the kind of thirty thousand-foot view, it’s easy to oversimplify it and not really look at the reality,” Williams says.
She says that in months of campaigning during the coronavirus pandemic and the subsequent economic downturn, she spoke with many voters whose sentiments about health care had shifted.
“We’re seeing through the pandemic that people are really losing their employment through no fault of their own, and they’re been left in a horrible situation,” Williams says. “So that idea of someone being undeserving when they’re impoverished or when they are unemployed or when they are uninsured is really countered by seeing their friends and family.”
Rural and small-town opposition to expansion was rooted in dissatisfaction with the current health care system, says Ryan Johnson, a senior advisor for United for Missouri, a conservative policy advocacy group. But it was also a rejection of the Affordable Care Act, under which Medicaid expansion is an option, he says.
“This is a central plank of the Obama administration. This is his signature issue and literally came to be known by his name: Obamacare,” Johnson says. “It has historically been unpopular in Missouri.”
The results seemed to align with the political leanings of the state's counties.
Approval of the Affordable Care Act tracks closely with party affiliation, with recent national polling by the Kaiser Family Foundation showing that, as of July, 72% of Republicans had unfavorable views of the federal law.
But across the population as a whole, the same poll shows that unfavorable views of the ACA have declined to their lowest level so far, with just 36% having an unfavorable opinion.
The negative views persist among rural residents, although many of these communities would appear to benefit greatly from expansion.
Many of the southern and southeastern counties that rejected expansion have rates of poverty and uninsured rates that are higher than those of Kansas City and St. Louis.
“Medicaid expansion would actually disproportionately benefit the rural areas,” says Dr. Karen Maddox, co-director of Washington University’s Center for Health Economics and Policy. “Because those are the areas that have high rates of people that are uninsured: the working poor, people who are working for small businesses that don’t provide insurance. We actually calculate that, on a per-capita basis, more money would go to rural areas than urban areas.”
Missouri’s “Yes On 2” campaign followed the model of other recent successful expansion campaigns in mostly Republican states, including Utah, Idaho, Nebraska and Oklahoma.
Expansion advocates enlisted the help of the Fairness Project, a Washington D.C.-based nonprofit that worked on other expansion campaigns and brought a similar approach to Missouri.
Jonathan Schleifer, executive director of the Fairness Project, agrees that, in Missouri, as in other states, many voters have a deep resistance to the ACA.
"I think there's still a lot of work to do to push back against the hundreds of millions of dollars, the public messages coming from as high as the White House, that there's something wrong with the Affordable Care Act," Schleifer says.
But Schleifer also says that the Missouri campaign convinced many rural voters of the importance of expansion and boosted their turnout.
A total of 672,967 Missourians voted in favor of expansion. Most of those votes came from urban areas, which voted overwhelming in favor of the measure. Kansas City voters, for example, voted to approve the measure by 87.7% to 12.3%.
Expansion supporters outside of the eight counties where majorities favored expansion, however, accounted for 30% of the total “yes” votes. Without those votes, the measure would have failed.
And county election results show that many rural voters across the political spectrum voted in favor of the measure.
Take Scotland County in northeastern Missouri, which had the highest uninsured rate in the state, 23%, in 2017. On Tuesday, 92% of Scotland County voters identified themselves as Republicans, but 36% of the county's voters approved of expansion.
Similarly, in southern Missouri’s Ripley County, where 17% of adults were uninsured in 2017, almost a third of voters approved of expansion, even though the county generally elects Republican candidates by huge margins.
Though the measure appeared to fail in rural places, these votes added more than 200,000 to the winning statewide tally.
The Missouri campaign rarely used the terms Affordable Care Act or Obamacare in its materials, and some mailers didn’t even include the phrase Medicaid expansion.
Health policy expert Rachel Nuzum of the Commonwealth Fund says that, when the politics are taken out of the equation, many voters tend to view Medicaid more favorably.
"What we've seen in our surveys over the years is when you take the labels off of the policies, when you take the Affordable Care Act label off, when you take Medicaid expansion off, and just start asking people whether or not you think low-income families should have access to Medicaid coverage, the support is overwhelming," Nuzum says.
To be sure, many conservative rural counties in Missouri did hew closely to historic voting patterns.
McDonald County, in the southwest corner of Missouri, has often voted for Republican candidates by 70% or more, and voters there rejected expansion by 71.7% to 28.3%. The county had an uninsured rate of 20% in 2017, the second highest rate in the state.
Regardless of how they voted, residents of both urban and rural counties will be eligible for Medicaid starting in July 2021 if they make up to 138% of the federal poverty level. A Washington University study published in 2019 estimates that 73% of people who are eligible will enroll in the program.
Maddox says it’s not clear whether someone might be less willing to enroll in Medicaid if they disapprove of the program.
But she says that Medicaid enrollment by people who live in rural areas would help both individuals and the state.
“The more people that the state can get enrolled, the more we can improve health,” Maddox says. “And frankly, in a time when we don’t have a great tax base, given the drop-off in the economy, the more federal money we can bring to stimulate the state’s economy.”
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