COLUMBIA, Mo. (AP) -- Missouri voters on Tuesday will decide whether to expand Medicaid health care coverage to thousands more low-income adults after years of resistance from Republican lawmakers.
The vote on health care, as well as primaries for statewide offices and congressional seats, comes as coronavirus cases are increasing in the state, which could impact voter turnout.
Missouri's Republican-led Legislature repeatedly rejected Medicaid expansion proposals over the past decade, which prompted supporters to turn to the initiative process.
Idaho, Maine, Nebraska, Oklahoma and Utah have all expanded Medicaid through ballot questions following inaction by state lawmakers, according to the nonpartisan Kaiser Family Foundation. Oklahoma became the 37th state to expand eligibility for Medicaid under the federal law last month.
Missouri's Medicaid program currently does not cover most adults without children, and its income eligibility threshold for parents is one of the lowest in the nation at about one-fifth of the poverty level.
The ballot proposal would expand eligibility under the terms of the 2010 federal health care law signed by President Barack Obama. That law provides a higher-than-usual federal funding share for states that expand Medicaid coverage to adults earning up to 138% of the federal poverty level, about $17,600 for an individual or $30,000 for a family of three.
Democratic Auditor Nicole Galloway's office estimated that expanding Medicaid could cost the state at least $200 million or save as much as $1 billion annually by 2026. Republican opponents cite the potential costs as reason to oppose the ballot initiative.
"Amendment 2 will be a knockout blow to the state budget as more services will be cut or eliminated to pay for the healthcare of able-bodied adults,” state House Budget Chairman Cody Smith said.
By proposing a constitutional amendment instead of a new law, Missouri supporters have ensured that lawmakers will be unable to change it without going back to voters.
Backers include the Missouri Hospital Association and groups with particular sway over Republicans such as the Missouri Catholic Conference and Missouri Chamber of Commerce and Industry.
Republican Gov. Mike Parson, who opposes Medicaid expansion and is up for election this year, in May moved the vote on the proposal up from the Nov. 3 general election to Tuesday's primary.
Galloway is trying to unseat Parson. Her campaign has said Parson switched the day of the vote on Medicaid because fewer people typically vote in August compared to November, possibly giving opponents a better chance of defeating the measure.
Voter turnout during the 2016 presidential general election in Missouri was almost three times higher than turnout for that year's August primary. Even in 2018, a record year for turnout during a primary, roughly 1 million more voters turned up at the polls in November compared to August.
Parson has said his decision was not about politics.
Voters on Tuesday also will pick the Republican and Democratic candidates for Congress, the Missouri governor's seat and other statewide offices, and state legislative seats.
Parson and Galloway have primary opponents, but both are expected to be nominated by their respective political parties.
St. Louis Circuit Attorney Kim Gardner, whose job performance has been lauded by some civil rights activists and criticized by President Donald Trump and other leading Republicans, faces a challenge from former homicide prosecutor Mary Pat Carl.