This fall, voters in Missouri will face a number of decisions: picking state and congressional representatives, the President. But also on the ballot will be a measure that like two years ago, has to do with the federal health law.
It follows months of political tension over a key component.
The federal health law envisions that by 2014, each state will have an online marketplace where individuals and small businesses can buy health insurance plans – plans that meet certain criteria and are more easily comparable. These marketplaces are also known as health insurance exchanges, and they can be run by either the state or the federal government. As it stands, an exchange does not exist in Missouri. Yet. And if it’s up to Missouri’s House majority leader Tim Jones, never will.
“We know that the citizens of the state of Missouri do not want the federal health care law, the Obama care law, or anything related to it,” Jones said on the final day of session last month.
Jones, a Republican, was speaking in favor of Senate Bill 464. The bill prohibits the creation and operation of a health exchange in Missouri unless the legislature or voters gives it the ok, and it prohibits the governor from creating one through executive order. The bill passed during those final hours of session, and will now be up for a popular vote in November. On the floor of the House, Jones said it’s a chance for Missourians to affirm their stance on the federal health law, like in 2010.
“71 percent of Missourians voted less than two years ago to prevent anything related to this,” said Jones.
The issue then was the federal mandate for buying insurance or paying a fine. Opposition to that is what voters wrote into the state constitution when passing Proposition C. Senator Rob Schaaf, a Republican from St. Joseph who sponsored this latest ballot measure, says a health exchange, not the entire health law, is his main issue.
“A health insurance exchange is a major policy decision, and it should require the input of the legislature,” says Schaaf. “That’s my concern for filing this bill.”
Schaaf says Governor Jay Nixon, a Democrat, previously went around the legislature’s back in trying to set up an exchange. His administration, the department of insurance, applied for and received a federal grant last year to start setting up the technical infrastructure for an exchange, including updating the state’s old Medicaid computer system. The administration channeled the funds to a quasi-government body that wasn’t subject to legislative oversight, and was getting ready to lay out some of the groundwork for an exchange.
“I was inflamed and decided to offer up this bill,” says Schaaf.
The group faced additional pressure from Schaaf and other lawmakers and has since suspended any health exchange activity, turning the grant money over to the legislature to appropriate. With many lawmakers waiting to see how the Supreme Court rules on the entire law before moving forward with anything, most of those grant funds are still sitting, unused, with the federal government.
Schaaf says he wants to further ensure nothing happens without the legislature and the public being on board. That’s why included in his ballot measure is the ability for people to sue any state agency or worker involved in any exchange activity.
Some people worry about this.
“I have a concern that that bill hanging out there will have a chilling effect,” says Andrea Routh, director of the consumer group, the Missouri Health Advocacy Alliance.
Routh says the ballot measure itself, even before it’s voted on, could cause Missouri to fall behind on preparing for an exchange, whether the state or federal government ultimately runs it. State workers might not do anything for fear of being sued, even though a lot has to happen for an exchange to be ready by 2014.
“It can really work well for families if we do it right,” says Routh. “But doing it right takes some work and planning and time, and people weighing in on how enrollment is going to work, and how our plan choices are going to be presented to us on this internet kind of platform. There are just so many decisions needing to be made, and if we’re waiting till the last minute to do it, there’s a potential that it may not be that workable for people."
If the measure does pass in November, it could be declared unconstitutional. Even so, Ken Warren, a political scientist at St. Louis University, says having it on the ballot won't help Democrats.
“They [Republicans] used opposition to Obamacare to win elections in 2010 and they will try to do the same in 2012,” says Warren. “Particularly to help defeat Obama by bringing out a lot of Republicans, getting them to the polls to vote not only against this measure, but while they’re there to vote against Obama.”
The fate of any health exchange and that of the entire health law, meanwhile, first and foremost rests on what the Supreme Court decides. Answers on that will be coming very soon. A ruling is expected by the end of this month.
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This story is part of a reporting partnership that includes KCUR, NPR and Kaiser Health News.
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