As you’ve probably heard, Governor Mike Parson played politics with our health in the middle of a massive health crisis. The story of the day is that Parson moved the vote on the Medicaid Expansion amendment from the November election up to August 4 (the Missouri state and local primary). As a result, he no-doubt hopes, the measure will fail due to lower voter turnout.
Before we get into why that is, though — and wrestle with questions like why anybody who claims to represent “the people” would want to schedule an important referendum for a low turnout election — we need to go back a few years. Two major milestones in the history of this Amendment are going to help you gauge how absolutely incensed you should be at Mike Parson’s attempt to kill it.
The story begins with Obamacare, otherwise known as the Patient Protection and Affordable Care Act. A centerpiece of President Obama’s campaign for president, the ACA set out to curb some of the most egregious abuses of the private insurance system, expand coverage to reduce the number of uninsured, and generally make healthcare in America more affordable and accessible.
On the cost side, the bill intended to cover more people through a two-pronged funding scheme. For people and families above a certain income level, the federal government would pay subsidies to lower the cost of private premiums. If you’re like me — steady job but far from wealthy— you’ve probably benefited from subsidies at some point. For a lot of people, they’ve made monthly premiums more realistic, and have contributed to many millions of uninsured people getting health insurance.
The subsidies were never meant to work by themselves, though. In order to cover everyone — which was an important part of achieving the bill’s goal of lowering costs — the bill also mandated that states expand the income eligibility requirements for Medicaid (state-run health insurance for certain groups of people, including pregnant women, children, needy families, the elderly, and the disabled.) In Missouri, the cutoff for Medicaid was and is tremendously low — non-disabled adults aren’t eligible no matter their income level, and parents with dependent children are only eligible if their income doesn’t exceed 22 percent of the poverty level.
Under the ACA, that eligibility was supposed to change dramatically, covering all residents with income levels up to 138 percent of the poverty level. Notably, the subsidies were written specifically with this in mind, only allowing subsidies for people with income levels over 100 percent of poverty. To help states shoulder the additional financial burden, the federal government was to pay 100 percent of the increased cost for the first three years, then 95% in 2017, 94% in 2018, and so on.
Now, the federal government can’t constitutionally order the states to do much of anything, much less expand a state-run program. But many times, Congress can achieve a desired regulatory result through its spending power. One of the most “law school” examples of this power was a 1984 bill raising the drinking age throughout the United States, which Congress accomplished by withholding 5% of all federal highway funds from any state that didn’t maintain a minimum drinking age of 21.
See how it works? “We can’t force you to do xyz because of federalism, but we are in control of a lot of the money you spend…”
Similarly, in the ACA, Congress tied strings to its Medicaid funding, withholding funds from any state that failed to expand Medicaid eligibility. Under then-existing case law, Congress had every constitutional right to do so — the Supreme Court had yet to strike down a congressional scheme founded on the spending power.
Still, after the ACA passed, 28 states filed suit (Missouri, then run by Democrats, didn’t join the suit). In a ground-breaking, fractured opinion, the Supreme Court ruled the Medicaid expansion mandate — tying federal funds to Medicaid expansion — was unconstitutionally coercive. Thus, states would have the power to refuse to expand Medicaid while still maintaining federal funding for their existing Medicaid programs. They could both have and eat their cake.
All of this history is important, because, as mentioned above, the subsidies and the Medicaid expansion provisions of the ACA were designed and meant to work entirely in tandem. If a state chose to forego Medicaid expansion, the only expansion of health coverage available would be through the subsidies, which are only available to people above the poverty line.
Thus, while more middle class folks were covered in Missouri, poor adults and many others were completely left out. The bill created, in the 14 states that didn’t expand Medicaid, a “coverage gap” of people too poor for the subsidies but not eligible for Medicaid. In Missouri, that gap includes an estimated 113,000 people.
According to one University of Michigan study, that gap unnecessarily kills 194 Missourians every year. Let that sink in before you move on.
So that’s the policy part — Missouri refused to expand Medicaid, and people died because of it. Now onto the second part — the politics.
In Missouri, like a lot of states, when lawmakers fail to do something important, We the People are able to jump in and do it for them. We did it when we rose up against Right to Work laws, passed a medicinal cannabis scheme, and enacted sweeping ethics reforms in 2018.
That task is tremendously difficult. An initiative campaign has to collect signatures equal to 8% of the total votes case for governor in the previous election in six of Missouri’s eight congressional districts. But through Herculean grassroots efforts, the people got it done on Medicaid Expansion. 341,440 signatures were presented to the Missouri Secretary of State on May 1, 2020, whose office validated the more than enough signatures to get the measure on the ballot and bypass the Republic supermajority in the legislature.
So it’s on the ballot and can’t be stopped. Now all it needs to do is pass, and democracy will triumph and Missourians will finally feel the full benefits of Obamacare.
That brings us to the third part of the story — where the governor tries to kill the initiative by placing it on low turnout election.
It is a sad-but-true fact of life that August primaries typically sport low voter turnout. Even during an election year, without an accompanying presidential preference primary, turnout in August in St. Louis City is low — in 2012, turnout was 26.77%; 20.29% in 2014 (a midterm year); 28.26% in 2016. As a Republican and an opponent of Medicaid expansion, Governor Parson knew what he was doing when he put the initiative on the August primary — low voter turnout always favors conservatives.
But the plan is flawed, in that it fails to account both for the importance and popularity of Medicaid expansion and for some very recent — and very embarrassing — local political history.
In 2017, as I alluded to earlier, Republicans passed a Right to Work law, preventing unions from signing contracts that require all workers to pay for union representation. Similar measures had been passed in other states, with devastating results for unions. With the supermajority on lock, Republicans had Right to Work in the bag — a victory for their corporate, anti-labor constituents and donors.
But, then, Missourians pulled off something of a miracle. Collecting 310,000 signatures, the People forced Right to Work onto the ballot. And in the August 2018 primary, no-doubt due to the ballot measure, voter turnout soared — in a midterm primary election, St. Louis voters turned out at a rate of 37.4% (nearly twice 2014’s turnout).
Right to Work was resoundingly defeated. Despite Republicans’ best efforts, unions and a groundswell of popular support won the day.
So the final question we have to ask ourselves is whether Governor Parson is right about us. We’re not going to show up, so Medicaid expansion will not pass.
We can bow to that status quo, and decide we’re alright with the inequity of the coverage gap and the unnecessary deaths it still causes. Or we can look at our own recent history, which tells us progressive change can flow from the ballot box, even when corrupt politicians in Jefferson City prevent it there.
I, for one, am voting Yes on Amendment 2, and my own campaign will encourage every voter we talk to to do the same. Because people are actually dying out there, and we can actually do something to stop it.
Whether you’re working on a campaign or not, you have to check on your neighbors’ voter registration statuses. You have to bug your friends until they threaten to block your phone number. You have to flood social media and knock on doors and make calls.
Because this one is life or death, and it hangs on how many people we can get to show up.
Matt Bell is a candidate for Democratic Committeeman in St. Louis’s 14th Ward. Find him on Facebook, Twitter, and Instagram. Register to Vote / Check Your Registration.
