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Health Exchange At Heart Of Missouri’s Proposition E


Proposition E specifically asks voters:

“Shall Missouri Law be amended to prohibit the Governor or any state agency, from establishing or operating state-based health insurance exchanges unless authorized by a vote of the people or by the legislature?”

The full bill also allows taxpayers to sue a state worker or agency over being involved with any part of the exchange process that’s not required by federal law, whether that be assisting a federal agency or providing resources.

The Affordable Care Act requires each state to have a health exchange up and running by 2014. 

What's an exchange?

Some have likened a health exchange to a Travelocity of sorts: an online market place where individuals and small businesses can go to compare and shop for, in this case, health insurance plans. It’s also a platform to help determine whether an individual is eligible for federal insurance subsidies or Medicaid. The exchanges can either be run by states, the federal government, or through a partnership. States decide. Some have already chosen to oversee their own, others have decided against it and others have yet to take action.

A mostly symbolic measure?

Although Proposition E specifically addresses the gubernatorial role in an exchange and in determining whether the state develops one, Democratic Governor Jay Nixon has already said he won’t move forward with one (ie: through executive order) without the approval of the legislature. His Republican challenger, Dave Spence, agrees and has said he has no plans to set up a state-run exchange.

Many opponents of the health law itself, like Republican House Speaker Tim Jones, have equated the ballot measure to a larger showdown on Obamacare. In 2010, Missouri voters passed proposition C, which opposed the law’s central mandate that people buy health insurance or face fines.

But other supporters and sponsors of Proposition E, like Republican Senator Rob Schaaf, say the measure is less about any one view on the exchanges or the health law, and more about reigning in the state’s executive branch and its abuse of authority. Last year, Schaaf and several other senators questioned the activities of some state agencies that were involved in drawing down federal funds that would have helped set up the infrastructure for an exchange. The process then came to a halt.

Some advocates of a health exchange and of implementing the health law, on the other hand, view this latest ballot measure as one more obstacle in the process of figuring out what’s best for Missouri. Groups like the Missouri Health Advocacy Alliance say a lot needs to be done to get an exchange up and running, whether that’s setting up the technical infrastructure for an exchange or figuring out how benefits plans will work. They worry that approval of Proposition E might create a hostile climate for moving forward with anything, whether the state or the federal government leads the way.

Beyond Prop E: The general election and the health law

Ballot measure aside, the general outcome of the upcoming election will likely affect what happens with an exchange in Missouri and elsewhere. Who wins the presidency and how many Republicans and Democrats gain Senate seats, for example, could play a role in determining the fate of the health law and its implementation. The composition of health-related committees in Missouri’s statehouse could also influence decisions about an exchange and about how other parts of the health law, like an optional Medicaid expansion, unfold in the state.


This story is part of a reporting partnership that includes KCUR , NPR and Kaiser Health News.


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