Missouri Medicaid expansion won in cities, but would have failed without these voters

Medicaid expansion prevailed in Missouri last week (53.2% to 46.7%) thanks to overwhelming support in urban areas and critical backing from suburban voters who have consistently elected Republicans.

Less obvious but just as important were rural Missourians. Usually written off as reflexively hostile to government initiatives, 1-in-3 rural voters (102,000) turned out for expansion. Without them, the proposed constitutional amendment would have failed by more than 20,000 votes.

“When you look at the way that specifically rural white Missourians have been voting in the last several elections but also generationally, there were a ton of people that clearly identify as conservative or Republican that came out and voted yes on this,” said Genevieve Williams, an organizer for Missouri Health Care for All, an organization that has advocated Medicaid expansion for more than a decade.

In 2016, Trump won all 79 of the Missouri counties defined as rural by the federal government. Not a single one of them favored Medicaid expansion. A closer look, however, shows that just three rural counties opposed expansion by a larger margin than they favored Trump.

For example, in southeastern Missouri’s St. Francois County, where Trump collected 70.6% of the vote in 2016, just 57.2% opposed expansion. Saline County, in central Missouri, was 64.5% for Trump and only 52.9% anti-expansion.

“There are a lot of counties that had 40% [in favor of expansion], 30% even, which is a little bit less exciting, but you still need that,” Williams said. ”It really was everyone showing up on Tuesday.”

While rural support for expansion was numerically respectable, it wasn’t necessarily popular. The Star sought out rural Missouri voters to discuss their support for Medicaid expansion, but Williams and other pro-expansion organizers were unable to find any such voters willing to go on the record — even when The Star offered them anonymity.

Williams said that too often, political rhetoric pits rural and urban voters against each other.

“While there is validity to just the terms ‘rural’ and ‘urban’ as a kind of divider in Missouri, it’s also kind of known to most of us to be a dog whistle...for Black and Brown communities versus white communities,” Williams said.

The anti-expansion campaign did its best to stoke racial tensions by playing into white rural voters’ prejudices.

Less than a week before the vote, the anti-expansion committee, No On 2 in August, sent out mailers warning that undocumented immigrants would crowd citizens out of Missouri hospitals if expansion passed.

“Amendment 2 would expand benefits for people who shouldn’t even be in our country, rewarding illegal immigration with taxpayer handouts,” read the mailers, which featured a person wearing a Mexican flag face mask.

Undocumented immigrants are not eligible to enroll in Medicaid — a fact the mailers failed to mention.

Williams said pro-expansion organizers in rural communities confronted race-based messaging head-on.

“Rather than running away from that, we ran towards it,” Williams said. “This is not accurate, and it’s wrong — like, it’s morally reprehensible — and we’re not going to allow that messaging to go unchallenged in rural Missouri,” Williams said.

“We didn’t just say, ‘Oh, it’s okay that this racist messaging is resonating with you. I’m going to message something else.’ We challenged that.”

The anti-expansion committee treasurer, Debra McClelland, and other committee representatives, did not respond to repeated requests for comment.

Neither did Republican state Senators Bob Onder, Denny Hoskins and Tony Luetkemeyer.

This story was originally published August 11, 2020 at 11:13 AM.