On Tuesday, August 4, 2020, the state of Missouri voted to expand Medicaid coverage under the Affordable Care Act (ACA). By a vote of 53 percent, Missouri citizens became the sixth state since 2017, forcing their state legislatures and governors to expand health insurance coverage under the ACA.

Missouri became the sixth Republican-led state where voters have defied political leaders, and it comes after Oklahoma voters took the same action earlier this summer. Other ballot-approved expansions of the ACA include Idaho, Utah, Nebraska, and Maine. The state of Virginia expanded its Medicaid after the state legislature switch parties.

The Missouri voter action means that a projected 230,000 low-income residents will now be covered through the state’s Medicaid program with people paying premiums on a sliding scale according to their income.

Before the pandemic, census data had indicated that the ACA, despite the many political hurdles, had reduced the uninsured number significantly from 50 million uninsured in 2010—before implementation to 28.3 million in 2018. There were significant differences in coverage gains between states that have adopted the ACA’s Medicaid expansion and those that held out. In expansion states, the uninsured rate has fallen from 18.4 percent in 2013 to 8.7 percent in 2018. In non-expansion states, the uninsured rate has dropped from 22.7 percent in 2013 to 17.5 percent this year.

The Supreme Court, in its 2012 decision upholding the ACA ruled in a way that made the Medicaid expansion optional. If states expand coverage, they receive a 90 percent match in the first years. Despite this, a dozen states still have not expanded coverage, including much of the South. The Missouri initiative was written in a way that will stop the legislature from adding restrictions.