By Lauren Flynn Kelly

Missouri voters on Aug. 4 approved a constitutional amendment to expand Medicaid coverage, reflecting a trend of ballot-driven expansion initiatives in recent years that has been accelerated by the COVID-19 pandemic.

Jerry Vitti, founder and CEO of Healthcare Financial, Inc., says he wasn’t surprised by the outcome “given that COVID is surging in Missouri and other states — I think that really argues well for states that have left it to the people via referendum.”

“In the context of COVID, you see the nonexpansion states getting hit really hard,” he continues. “And I think it accelerates the impulse to expand coverage because, first of all, it’s good for people, period. And folks with underlying conditions, social conditions and disparities are the most vulnerable, so with the spread of COVID there should be the realization that coverage is more important than ever.”

Katherine Hempstead, Ph.D., a senior policy adviser with the Robert Wood Johnson Foundation, suggests that the pandemic has altered public opinion more favorably toward expanding Medicaid.

Moreover, the political sentiment that Medicaid isn’t an acceptable long-term solution to covering “able-bodied” adults “has been slowly eroded over time, and I think these ballot measures are showing that even in states that are pretty conservative, that’s not a majority view,” continues Hempstead.

Absent ballot measures, however, how will states proceed? “Of the states that are left, I would be shocked if we’d get a legislative expansion of Medicaid during COVID.…[W]hen you’re trying to close massive budget gaps, that 10% of the cost [that states must bear] is still a lot of money in real terms, particularly when you’re looking at more and more people eligible for Medicaid expansion if the economic effects of COVID drag on,” weighs in Chris Sloan, an associate principal with Avalere Health.

While providers are typically part of any major push for Medicaid expansion in a state, federal legislation allowing them to be reimbursed at Medicare rates for providing COVID-related care to uninsured individuals essentially “blunts what could have been a bigger push from providers,” he suggests.

“It takes time and effort to get expansion on the ballot,” and not all states have the mechanisms in place to allow for ballot measures, Sloan says.