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--:-- Sean Rameswaram: Not all journalism is the same. Take The Guardian. Our coverage has something unique, fierce independence. Nobody owns us or tells us what we can and can't say, so we're free to report the whole picture. We connect what's happening in Washington to the rest of the globe, expose corruption wherever we find it, and give fresh perspective on everything from wellness and soccer to culture, the climate and more. Read, watch and listen to The Guardian for free at theguardian.com.
--:-- Sean Rameswaram: The United States is a democracy, right? Well, actually, Sean, it's a little bit more complicated. We live in a constitutional federal republic, and I'd like to place emphasis on the republic bit. While people hold power in the United States, that power manifests in representatives, i.e. elected officials exercise power on behalf of the people.
--:-- Sean Rameswaram: Oh, right, right, right, right, right. And that's why they can't get Medicaid expansion in Missouri. Jason Rosenbaum with St. Louis Public Radio was just telling us about this. We passed a constitutional amendment in 2020 requiring people that make up to 138% of the federal poverty level, so that's a little over $17,000 a year, to have access to the health care program that is kind of the state-federal combination, so to speak.
--:-- Sean Rameswaram: It's now official. Missouri will be the 38th state to expand Medicaid, meaning an estimated 230,000 more Missourians will now qualify for the program. A lot of people like me thought this issue had been settled after a 15-year fight. Dozens of organizations, from health nonprofits to charities and even the conservative-leaning Missouri Chamber of Commerce support expansion, including St. Luke's Hospital, where uninsured patients often use the ER for primary care.
--:-- Sean Rameswaram: But that wasn't the case because the legislature made the decision not to fund Medicaid expansion. This is the left's overindulgence in a Robin Hood complex of constantly trying to take from those who have earned to give away to those who have not.
--:-- Sean Rameswaram: As a result, the Republican governor, Mike Parson, decided to withdraw documentation to the federal government to expand Medicaid. The legislators did what they thought was right. Whether we agree with it or not, that's how they're set up. This is how democracy is set up. And they both chose not to fund it.
--:-- Sean Rameswaram: And all sides agree that we are entering a lot of uncharted legal territory. And we are also entering probably one of the most high stakes pieces of litigation maybe in the state's modern history about whether this constitutional amendment requires people to have access to Medicaid or whether not funding it essentially renders it null and void.
--:-- Sean Rameswaram: Well, let's talk about how we got here. 15-year fight to expand Medicaid, you said? In 2005, Republicans took control of state government for the first time in Missouri's modern history. They had a Republican governor and they had a Republican legislature. And they decided to cut Medicaid to people that are truly destitute or don't have any income, as opposed to people who are part of the working poor.
--:-- Sean Rameswaram: This was a very controversial decision, but it's a decision that remained in place even after Missouri elected a Democratic governor in 2008, Jay Nixon. We've worked hard to lay out a clear plan we can afford to make a difference to Missourians. That plan has three steps. First of all, we'll restore these Medicaid cuts, which were wrong and have caused us to have $1.5 billion we've turned down of federal dollars.
--:-- Sean Rameswaram: Even though Nixon wanted to expand Medicaid and essentially bring the program back to the working poor, he did not have enough support in the legislature to do that. And that support did not get any larger after the Affordable Care Act passed. There was pretty generous subsidies from the federal government. And when I say generous, I'm talking like 100 percent for a few years and then it goes down to 90 percent.
--:-- Sean Rameswaram: Well, after a while, the state's hospitals especially kind of got fed up of this situation. They, along with a number of other groups, helped fund a ballot initiative in 2020 that got enough signatures before the pandemic happened that was able to mount a well-funded and well-organized campaign and was able to convince a majority of Missouri voters to, expand Medicaid in the state's constitution.
--:-- Sean Rameswaram: Missouri families have waited long enough. It's time to let the voters decide what's best. Join us. Join us. Please join us. Help us deliver health care for Missouri.
--:-- Sean Rameswaram: And now the legislature is trying to test whether that amendment actually matters if it doesn't have funding attached to it. I think there's a great difference of opinion about who's right, but it's pretty clear that if you read the constitutional amendment, it says that by July 1st, Missouri has to start providing the program to people that make, I think, 138% of the federal poverty level.
--:-- Sean Rameswaram: Let's talk about this ballot measure. How did it get on the ballot to begin with? It got on the ballot because primarily hospitals were kind of fed up with the status quo. Hospitals have to take in people even if they don't have the ability to pay for their medical care. And that can be a very expensive thing for hospitals.
--:-- Sean Rameswaram: And they would much rather have a situation where people would have access to Medicaid and then Medicaid could reimburse a lot of the costs that are associated with giving people health care There are a lot of complex reasons why rural hospitals in Missouri especially have shut down over the last few years And I don't want to oversimplify things and say not expanding Medicaid is the only reason.
--:-- Sean Rameswaram: But a lot of business leaders and a lot of people that oversee the hospital industry here feel like the lack of Medicaid expansion has gone hand in hand with the shrinking footprint of rural health care. Since 2014, 10 rural hospitals across the state have closed their doors, and the Missouri Hospital Association believes Medicaid expansion will slow that problem by reducing the amount of uncompensated care many rural hospitals provide.
--:-- Sean Rameswaram: So when you can begin to push down that level of uncompensated care, even if you're getting paid 60 or 70 cents on the dollar for providing care under Medicaid, That's 60 or 70 cents on the dollar that you weren't getting when you were providing uncompensated care.
--:-- Sean Rameswaram: Traditionally, Republican groups like the Missouri Chamber of Commerce saw this situation as untenable. And so that's why you had a pretty diverse coalition that included some traditionally Republican business groups band together with progressive and Democratic activists to get this across the finish line. And they succeeded.
--:-- Sean Rameswaram: Amendment 2 passed yesterday by a 53 to 47 percent margin. The Vote Tuesday approving Medicaid expansion in Missouri is the end of a years-long, hard-fought battle. So the ballot measure passes in August of 2020. What happens next?
--:-- Sean Rameswaram: A lot of people like me thought that this issue was over. In fact, Governor Mike Parson used part of his State of the State speech. It is an honor to stand before you today as the 57th governor of the great state of Missouri. To say he doesn't like Medicaid expansion, but the people voted for it. I will always uphold the will of the voters.
--:-- Sean Rameswaram: And I am including money for Medicaid expansion in my budget. And we will move forward with the expanding Medicaid coverage to approximately 275,000 Missourians. But it doesn't happen. It does not happen.
--:-- Sean Rameswaram: We're not going to throw out the neediest families in Missouri. We're not going to make them wait in line so that able-bodied Missourians can have their free Medicaid. How do Republicans justify circumventing the will of the people, quite literally?
--:-- Sean Rameswaram: They justify it by saying that the ballot measure, by not including a specific way to fund Medicaid expansion, was misleading to voters. I think if voters had the opportunity to choose, given all the information, I don't believe they would have overwhelmingly passed Medicaid expansion because the costs have to come somewhere.
--:-- Sean Rameswaram: They have said that if there was a specific funding source, like let's say it was attached to a tax increase, that it probably wouldn't have passed. And I actually think I've talked to a couple of lawyers. I do think that the Republicans are right in the sense that there is no requirement to fund this.
--:-- Sean Rameswaram: It's just that if they're wrong, and in the sense that the state has to start signing up all of these people to Medicaid, the consequences are going to be pretty dire if they don't end up funding expansion. So I think that primarily their argument has been about the long-term costs of Medicaid expansion and their fear that if the costs are out of control five-plus years from now, they're going to have to cut education or they're going to have to cut other things that are seen as needs.
--:-- Sean Rameswaram: A lot of Democrats don't find that argument convincing. They point to other states that have expanded Medicaid, and they really haven't seen those out-of-control costs. But this isn't over yet, right? A week ago, a lawsuit was filed over the funding questions around this Medicaid expansion.
--:-- Sean Rameswaram: What comes next? Somebody is going to try to apply for Medicaid on July 1st who would have been eligible if expansion had been funded. They're going to get rejected, and they're going to file a lawsuit. And this case will almost certainly go to the Missouri Supreme Court.
--:-- Sean Rameswaram: They're going to have to decide this very simple question. Does this constitutional amendment require people who are eligible for Medicaid, up to 138% of the federal poverty level, to get Medicaid? If the answer is yes, I would say that the legislature has no choice but to fund it, even if it is not required to be funded.
--:-- Sean Rameswaram: If the answer is no, because the courts say this constitutional amendment doesn't go into actual effect unless it's funded, then essentially the constitutional amendment is pretty worthless unless the legislature changes course and funds it.
--:-- Sean Rameswaram: That's why I've been saying this is such a high stakes court decision because it really is going to decide whether 275,000 people, roughly, are going to have access to pay for health care. I would be able to attend doctor's offices without spending $160-some-odd every time.
--:-- Sean Rameswaram: Autumn Stoltz, who works as a caregiver for her mother. I see a bunch of money-hungry pigs that don't want to give out the money that we so rightly have put in. Beyond the people that are actually affected by this, it remains to be seen whether this issue is going to compel Missouri voters to kick people that aren't following through with Medicaid expansion out of office.
--:-- Sean Rameswaram: And they're not listening to the Missouri voters. They're not listening to their constituents. And it's really ticking a lot of people off, to be brutally honest, that they think that it's all about them when it's not. If it wasn't for our voters, they wouldn't be sitting right where they're at now.
--:-- Sean Rameswaram: The reality is in Missouri that we're a much more Republican state than we were in 2005. The rural areas are voting for Republican candidates anywhere from 60 to 85% of the time. And there have been a lot of predictions by Missouri Democrats that, you know, there's gonna be an issue that causes that to change.
--:-- Sean Rameswaram: And that just never has happened. Like the Republicans have been able to do a lot of things that have caused controversy and they have literally lost no ground significantly in the legislature And I think that a lot of Medicaid expansion proponents are hoping that this is the tipping point But if it was the tipping point, well, why did the Republican legislature get more Republican when Republicans refused to expand Medicaid in the 2010s, when the federal government was going to pay for everything?
--:-- Sean Rameswaram: I think it's going to be really telling what ends up happening in some of these state legislative races where people that decided not to expand Medicaid, sometimes very forcefully, have to go before voters again. Jason Rosenbaum, he's with St. Louis Public Radio. You can find and support his work at stlpublicradio.org.
--:-- Sean Rameswaram: Quick break, and then we're going to dig into how often lawmakers bypass direct democracy. Support for today's show comes from Adio. What is Adio? Adio Adio is an AI native customer relationship management system built specifically for the next era of companies.
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--:-- Sean Rameswaram: And they say you can build AI-powered automations and use its research agent to tackle some of your most complex processes to seize so that you can focus on what matters, building your company. You can join industry leaders such as Flatfile, Replicate, Modal, and so much more. You can go to adio.com slash todayexplained to get 15% off your first year. That's A-T-T-I-O dot com slash todayexplained.
--:-- Sean Rameswaram: explained. Goldman Sachs Bank, USA, Salt Lake City Branch. Terms and more at applecard.com. All right, we're back. When we heard about this situation in Missouri where the people voted for one thing and the lawmakers were like, no. We want to know how often this kind of thing happens.
--:-- Sean Rameswaram: So we reached out to Sophie Quinton. I'm a reporter for Stateline, which is a news outlet affiliated with the Pew Trusts. And we asked her, how often does this kind of thing happen? My sense is that it is quite extreme in that lawmakers are basically saying we're not going to fund a program that's now written into the state constitution.
--:-- Sean Rameswaram: You know, I think there's going to be a big court battle over that and kind of we're not really sure how exactly that's going to play out. But in general, it is quite common for ballot initiative backers to say, you know, lawmakers aren't implementing this in the way we wanted, aren't funding it in the way we wanted.
--:-- Sean Rameswaram: And that's because when you try to create new law via ballot initiative, you're basically putting something on the books without any control over what lawmakers are going to do, what regulators are going to do, what the courts are going to do. So, you know, some ballot measures are very long and complicated because, you know, the folks who are writing them are trying to make sure they're implemented, you know, in a very exact, precise way.
--:-- Sean Rameswaram: But, you know, ultimately, they don't have control over that process. So there is often tension between ballot initiative backers and lawmakers over how these new laws are implemented. And is it always Republicans pushing against the will of the people in the way we're seeing in Missouri? Or is this a bipartisan effort to undo the will of the people?
--:-- Sophie Quinton: Well, the political scientist who I spoke to about this said that historically, this is kind of a bipartisan tension because often groups will pursue ballot initiatives if they have a policy idea that has no chance of making it through the normal lawmaking process.
--:-- Sophie Quinton: So if a state is totally controlled by Democrats, Republicans might try to push a ballot initiative that, you know, otherwise wouldn't get passed because of the composition of the legislature. The tension that we're seeing over ballot measures reflects progressives and left-leaning groups trying to get ideas like Medicaid expansion on the ballot because they know that, you know, they don't have a chance of getting this idea through the legislature.
--:-- Sophie Quinton: So we do see kind of a partisan tension right now. But historically, that hasn't always been the case. It's not only Republicans that are opposing these things. It tends to be the party that controls the state legislature that is pushing back because they want to do things their way.
--:-- Sophie Quinton: And sometimes ballot measures are, you know, advancing an idea that they don't really support. And I believe something like half the states have some kind of direct democracy process. Are we seeing more ballot initiatives because there are presently more state houses controlled by Republicans?
--:-- Sophie Quinton: So according to Ballotpedia, which is an online election encyclopedia, there were 76 citizen initiative ballot measures, which is the kind of thing that we're talking about, on the ballot in 2016, which is the most that they had seen in their tracking since 2006.
--:-- Sophie Quinton: Obviously, you know, 2020 was another big presidential election year, but it was a little bit different because of the pandemic made it a little bit harder to kind of run a campaign to get a ballot measure on the the ballots. So last year, it's a little hard to see a trend. But in general, we do seem to be seeing an uptick in these initiatives.
--:-- Sophie Quinton: And we heard that there are these arguments being made in Missouri that voters may have been manipulated into voting one way or the other on this Medicaid expansion. Is there credence to that argument that sometimes these ballot measures are tricky, are deceptive, or that we shouldn't subject our state constitutions to a process like this?
--:-- Sophie Quinton: I think it's fair to say that some ballot initiatives might be written in a simplistic way when really the issue is really complicated. I mean, take this Arizona tax increase to fund education, for instance. Voters pretty split on this one with about 54 percent voting yes.
--:-- Sophie Quinton: If approved Prop 208 will impose a tax increase on the top 1 percent of earners in the state to fund public education There sort of a battle in the state between Republicans and Democrats on whether that tax increase impacts small businesses or not OK, so because it does tax the income that high earners report as business income.
--:-- Sophie Quinton: So Republicans will say that affects small business owners. You lied to voters when you said that this was not going to hurt small businesses because clearly it does. Whereas Democrats or the supporters of the initiative will say, you know, this is, I mean, the people who are reporting business income who are wealthy are not mom and pop shops.
--:-- Sophie Quinton: You know, they're millionaires, they're hedge fund managers. This isn't about small businesses. So it like hinges on what you consider to be, quote unquote, small. So it's interesting.
--:-- Sophie Quinton: I think in every state, in every measure where there's a sort of a back and forth about whether voters were misled, it's a little bit different. I hadn't heard about that one in Arizona, but another one that comes to mind is marijuana.
--:-- Sophie Quinton: We've seen referenda across the country to legalize weed. And it seems like that's a really good example of these ballot measures, however confusingly or deceptively worded they may be. And serving this crucial role in our democracy, advancing, you know, a policy position that the people have largely accepted while many state governments, even President Biden, you know, have not.
--:-- Sophie Quinton: Marijuana is a great example of an issue where, you know, it has passed in some states by a pretty wide margin and is sort of obviously something that people are in favor of. It does seem to me from the reporting that I've done that when an initiative passes by a really wide margin and is clearly showing that voters in a state want that to move, it is pretty hard for lawmakers to say no to that.
--:-- Sophie Quinton: I mean, I think bringing things back to Missouri, what's interesting about that initiative is that a pretty small share of registered voters in the state actually participated in that and voted for it. And then it becomes easier for lawmakers who disagree with that idea to say this doesn't represent my constituents.
--:-- Sophie Quinton: You know, Missouri is a conservative state. They voted for me. They voted for a Republican governor. You know, the margin by which something passes, I think, can have an impact on this debate over whether it really represents what people want in that state.
--:-- Sophie Quinton: Does it feel at this point that, you know, the politics of this country have become so divided that ballot initiatives are something of a last resort for the democratic process?
--:-- Sophie Quinton: Yeah, I think it depends on what you mean by democratic process. typically when laws are made in the regular legislative process there's some attempt to balance you know that a budget has to be passed there has to be a way to pay for it you know there's kind of a complicated dynamic and discussion that has to happen whereas in a ballot initiative it can just say we want to cut taxes and voters will be like yes I do want to cut taxes or it will say we want to fund, you know, education or we want to fund health care.
--:-- Sophie Quinton: And voters will say, yes, I want that. That's only part of the debate for making law, right? It's like you have to figure out how to balance taxes and services and how to pay for everything. And voters, when they're voting on these single issue initiatives, don't have to do that. But lawmakers have to do that.
--:-- Sophie Quinton: So it kind of, you know, there are some things that get on the ballot that pass, that make Republicans really happy and make them think that voters are really on their side and that there's a ton of public support for cutting taxes, which, you know, people don't like paying taxes, so they may not be wrong in that.
--:-- Sophie Quinton: But, you know, it's kind of because of the way that these initiatives are written and the fact that they're isolated from the rest of kind of the sausage making of making law and balancing a budget, it kind of becomes easier for folks on really a variety of issues or sides of issues to say, there's a lot of support for our idea.
--:-- Sophie Quinton: What you're saying is when you hear a lawmaker making the argument that, you know, the people really can't be trusted with this hefty democracy, they kind of have a point?
--:-- Sophie Quinton: I'm just saying the process is complicated and the average voter doesn't have to make those kinds of choices and think about the whole sum of how to run a state or how to run a city. The average voter can just say, yes, I want more parks. Who doesn't love more parks?
--:-- Sean Rameswaram: Yeah. Well, it's just interesting, right? Because it's all about like, what, is it a representative democracy? Is it direct democracy? I think both sides do have an argument that they represent the will of the people. It's a lot about that philosophical question. It's about heavy issues. And it's also about politics. As it always is.
--:-- Sean Rameswaram: Yeah, right. Sophie, thank you so much for your time. I really appreciate it.
--:-- Sean Rameswaram: Yeah, thank you. Sophie Quinton, she's a reporter with Stateline over at Pew Trusts. I'm Sean Rameswaram for him. This is Today Explained. And if you saw a video of wrestler, rapper, and soon-to-be Fast and Furious star John Cena apologizing to China in Mandarin about something he said about Taiwan and had lots of questions, you are not alone. For some answers, check out the Worldly podcast from Vox. Our colleagues over there are digging into what exactly was going on in that video on this week's show. Find it wherever you listen.
--:-- Sean Rameswaram: Thanks. Thank you. Thank you.
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