By Alec MacGillis
Washington Post Staff Writer
Thursday, August 5, 2010; A03
A day after Missouri voters rejected a key component of the nation's new health-care overhaul, Republicans seized on the result as conclusive evidence that Americans don't like the law.
Primary voters in Missouri were the first to vote directly on the law, in a ballot referendum that prohibits the federal government from requiring people to have health insurance. The measure passed 71 percent to 29 percent.
Supporters of the overhaul played down the vote, noting that it has no practical impact and that Tuesday's electorate was largely Republican. But they conceded that a lack of public support could make it hard to put the law into practice.
Lawmakers in several other states, such as Virginia, have already passed laws rejecting the "individual mandate," a central feature of the health-care overhaul. The state laws, including Missouri's, are largely symbolic because they are trumped by federal law.
More consequential are the legal challenges that have been brought by Republican state attorneys general, including a lawsuit by Virginia's Ken Cuccinelli II. A federal judge ruled Monday that Virginia's suit can go forward, rejecting arguments from the Obama administration that the state had no standing to sue.
Regardless, Republicans said Wednesday that the vote in Missouri marks a turning point in the health-care debate.
"It sends a big message to the country," said Rep. Roy Blunt, who won the Republican primary in Missouri's Senate race. "This is the first time voters have had a chance at the ballot box to register their feeling about this bill. [House Speaker] Nancy Pelosi and [Senate Majority Leader] Harry Reid kept saying, 'We know people don't like this, but once we pass it they're really going to like it.' Well, as it turned out . . . they still don't like it."
But supporters of the national law argued that the electorate was far from representative. Turnout was far higher on the Republican side, where Blunt was facing a more competitive field than Missouri Secretary of State Robin Carnahan was on the Democratic side.
About two-thirds of the voters participated in the Republican Senate primary, and turnout in Democratic strongholds such as St. Louis and Kansas City was among the lowest in the state. And Missouri in general is conservative on health-care policy -- its Medicaid eligibility policy is among the most stringent in the country.
The overhaul's backers also pointed to national polls that show an uptick in support for the new law. "We're trying not to read too much into it, because we know it's a very small percentage of registered voters and that very conservative primary races were being decided," said Amy Blouin, founder of the Missouri Budget Project, a liberal advocacy group.
The national law broadens coverage through three interdependent steps: insurers must offer coverage to people with preexisting conditions; to make this affordable for insurers and to keep people from waiting until they get sick to seek coverage, everyone be insured; and to help people afford coverage, the government offers income-based subsidies.
Blouin said there is a lack of clarity about the mandate's context in Missouri, where 14 percent of people under age 65 don't have coverage. "People don't understand that the mandate is not happening in a vacuum," she said. "Middle-class families, small businesses will all benefit from support."
Opponents say the mandate is unconstitutional because it forces people to buy a commercial product. Supporters, and many legal experts, say it falls within the government's power to tax and regulate interstate commerce.
But even if the mandate survives in court, the federal government and the states will face major challenges in getting people to comply. The requirement goes into effect in 2014, and penalties for not buying insurance will eventually rise to a maximum of 2.5 percent of income.
In Massachusetts, which included a mandate in its 2006 universal coverage law, most people have complied -- but only 9 percent of residents had been uninsured, and there was a bipartisan consensus on the law. Getting people to comply will be more difficult in states with far larger numbers of uninsured, with elected officials who are railing against the law and with electorates that are far more resistant, as Missouri's vote suggests.
"Implementation . . . really does require significant state support," said Harvard health policy expert Robert Blendon. "You could end up with a bifurcated country -- with some states getting ready and others doing as little as possible."
Jon Kingsdale, who ran Massachusetts's health-care program until recently, is more optimistic. While the mandate is the most tempting target for the law's opponents, he predicted that more and more state officials will start preparing for it as 2014 approaches.
"As we get closer to 2014 -- and if those who oppose it don't succeed in tearing it apart -- the momentum builds," he said.