The continuing war over President Obama’s health-care law is particularly fierce this election season in Missouri, where politicians of both major parties are playing a game of can-you-top-this with a ballot referendum whose chief result promises to be voter confusion.

In May, the General Assembly approved a ballot measure that would require voter or legislative approval of a cornerstone of the health law: creation of an online state insurance exchange for individuals and small businesses to buy coverage.

The Republican-controlled legislature is trying to block Gov. Jay Nixon, a Democrat, from establishing an exchange by executive order — something he says he doesn’t plan to do.

What the November ballot initiative all but ignores, however, is that if the state does not implement a health-care exchange by 2014, the law requires the federal government to impose its own version.

Missouri Secretary of State Robin Carnahan, a Democrat who is not running for reelection, is responsible for explaining difficult ballot measures to the voters. She clearly spotted the hole in the initiative language and, in early July, decided to make her own political statement. Her summary, to appear on the ballot on Election Day, did not use a light touch:

“Shall Missouri law be amended to deny individuals, families, and small businesses the ability to access affordable health care plans through a state-based health benefit exchange unless authorized by statute, initiative or referendum or through an exchange operated by the federal government as required by the federal health care act?”

‘Not fair . . . not accurate’

Republicans were outraged, none more so than Lt. Gov. Peter Kinder, who stepped in “within minutes of publication,” he said in an interview. This “biased, loaded” language “is not fair, it’s not accurate, it’s not impartial. We have to get this into court.” So he filed suit to have Carnahan’s summary thrown out.

Since then, Kinder, who is running for reelection and is locked in a tough race against several opponents in Tuesday’s Republican primary, has used the initiative and his opposition to the health-care law as a centerpiece of his campaign. “The whole entire law was founded in lies, passed with lies and is based in lies now, and the American people are not going to stand for it,” Kinder said. “Certainly the people of Missouri are not going to stand for it.”

‘Good political theater’

Carnahan’s office said that as the defendant in the case, Carnahan would not comment publicly on Kinder’s accusations, but she was clearly unmoved: “Obviously, some candidates see this as good political theater during an election year,” Carnahan spokesman Ryan Hobart said in a statement, “but we maintain that this is a fair and sufficient summary of the ballot measure.”

Theater or not, the Missouri referendum has served as a reminder of the important role health care will play in this year’s elections. It also demonstrates how health-care hyperbole can drown out reasonable discourse.

Nationally, opinion on the health-care law remains volatile and deeply divided. Although no recent polls have tested the Affordable Care Act’s popularity in Missouri, another largely symbolic ballot initiative exempting Missourians from mandated health insurance won 71 percent of the vote in 2010. A July 28 poll this year showed Obama trailing presumptive Republican nominee Mitt Romney by nine points.

“President Obama and the health-care law in general are not popular in Missouri,” said George Connor, head of the political science department at Missouri State University, in Springfield. “Any opposition to President Obama on health care by anybody gets you bonus points with the voter.”

Democrats, Connor added, are trying to stay clear of Obama. The popular and politically savvy Nixon has been successful at it and is a clear favorite for reelection. U.S. Sen. Claire McCaskill, however, a supporter of the health-care law who is closely identified with the president, is trailing any one of three possible GOP opponents competing in the primary.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.