Missouri voters joined 38 other states (including DC) and adopted Medicaid expansion yesterday by a vote of 53% to 47%. The vote gave Missouri the distinction of being the sixth state to pass Medicaid expansion by a ballot vote, usually over the objections of Republican leadership in each state. The vote followed a familiar rural/urban split, with rural voters much less likely to support expansion in contrast to strong support from urban areas. However, minorities of voters in rural areas consistently support expansion combining with urban support to create a winning coalition for more affordable health care in state after state. Notably, the states that have voter-passed expansion are generally very conservative. Republicans are joining with Democrats to pass the measures as health care becomes an increasingly important issue to voters.

Missouri’s vote totals were similar to Nebraska’s and not at all as close as Oklahoma’s squeaker of a vote in June. The final vote totals from the states that have passed expansion by ballot:

Maine passed 59% to 41%

Idaho passed 61% to 39%

Nebraska passed 53% to 47%

Utah passed 54% to 46%

Montana failed 45% to 55%

Oklahoma passed 50.5% to 49.5%

Missouri passed 53% to 47%

Note that the one state where a ballot measure renewing Medicaid expansion has failed – Montana – linked the expansion to a substantial tobacco tax increase that drew significant opposition from the tobacco industry. (Montana eventually renewed Medicaid expansion through the legislative process.) The ballot measures have been supported by painstakingly-built state-based coalitions and coordinated through an effective national campaign, the Fairness Project.

As in every state that has passed a Medicaid expansion ballot initiative, passage of the measure does not insure implementation of actual health care coverage. After passage, policymakers in each state have spent months, and even years, trying to enact barriers to the new coverage, delaying implementation (Nebraska just started enrolling people this month after nearly two years of delay), and Maine’s former Governor even vowed to go to jail rather than begin providing more health coverage to state residents.

Oklahoma and Missouri voters have done the hard work of letting their leaders know Medicaid expansion is a winner. Now advocates face more work to make sure their leaders don’t try and dilute or delay the new coverage. But with these votes, the wind is at their backs.