No matter how hard they tried, Republican politicians and their allies could not stop Missouri’s voters from expanding access to Medicaid under the Affordable Care Act.

They tried to rig the timing of the referendum by forcing the vote during a relatively low-turnout primary on Tuesday rather than in November. That failed. They played on racial prejudice and nativism by falsely claiming a yes vote would mean “illegal immigrants flooding Missouri hospitals . . . while we pay for it!” That failed, too.

And so did Missouri this week become the sixth state since 2017 — five of them staunchly Republican — where voters took the decision on the expansion of health coverage out of the hands of recalcitrant conservative politicians.

In joining Idaho, Utah, Oklahoma, Nebraska and Maine, the place known as the “Show Me State” showed the electoral power of access to health care and the danger to President Trump and Republicans of their ongoing efforts to repeal Obamacare.

The 53 percent to 47 percent victory to extend health coverage to well over 200,000 Missourians was built on large margins in the Democratic cities of St. Louis and Kansas City. But what should disturb Republicans is that, in suburban areas, including places they had carried in the past, voters supported the referendum or opposed it by much smaller margins than the GOP is accustomed to winning.

Jason Hancock, the Kansas City Star’s lead political reporter, noted that largely suburban Platte County, which narrowly supported Sen. Josh Hawley (R-Mo.) in 2018, gave 61 percent of its ballots to the Medicaid expansion. And while rural Republican counties around the state voted no, the margins against the Medicaid referendum were smaller there than Trump’s advantage over Hillary Clinton in 2016.

“Our rural areas will benefit significantly from this,” said Amy Blouin, executive director of the Missouri Budget Project, which supported the referendum. “We’ve had 10 rural hospitals close in recent years and rural counties are worried about losing more hospitals, which are economic engines for their areas.”

All but 12 states — eight of them in the old Confederacy — have now expanded Medicaid. And the evidence is strong that if their voters were given the chance, they, too, would decide for expansion. In May, the Kaiser Family Foundation (KFF) Health Tracking Poll found that in the states that had not accepted Obamacare’s Medicaid offer (which then included Missouri and Oklahoma), 66 percent favored expansion. “Even in red areas of red states, there is some support for expanding Medicaid,” said Liz Hamel, KFF’s director of public opinion and survey research, noting that the May survey found 37 percent of Republicans favoring the step.

While Missouri is one of the states Trump can still count on against former vice president Joe Biden this November, the health-care issue is clearly hurting the president and his party even among voters who make up the base of the GOP.

“While Trump still has a substantial lead with small-town and rural White voters, it is significantly less than he won in 2016,” said Geoff Garin, a Democratic pollster. “And his failure to deliver on affordable health care is the number one reason driving those voters away from him. When Trump promised in 2016 to deliver more affordable health care to more people, his voters took that seriously.”

Beyond general dissatisfaction with Trump, health care was far and away the most powerful Democratic issue in the 2018 midterm elections, and it continues to be important in Senate and House races this year. In his campaign to unseat Sen. Steve Daines (R-Mont.), for example, Democratic Gov. Steve Bullock recently ran an ad touting his success in expanding Medicaid and its benefits to “rural hospitals all across Montana.”

Whit Ayres, a Republican pollster, said he was not surprised by the result in Missouri. “The explanation is not complicated: covid-19,” he said. “When thousands and thousands of people are getting so sick with a dastardly disease that we know so little about, it’s not surprising that people will vote for affordable health care — especially when there’s no coherent alternative on the table.”

At some level, Trump seems to understand the costs of having failed to offer that “coherent alternative,” even as he continues to support a lawsuit that would scrap Obamacare altogether. But instead of outlining a policy, he keeps making laughably empty promises. His latest came during a July 19 interview with Fox News’s Chris Wallace, whom he told: “We’re signing a health-care plan within two weeks, a full and complete health-care plan.”

The two weeks expired a few days ago.

Voters may be inured to empty promises, but they take their own and their family’s health care very seriously, especially during a pandemic. If Biden wins in November, one of the reasons will be his pledge to build on the Affordable Care Act. And as Missouri’s voters showed, there will be many grass-roots Republicans quietly cheering him on when he tries to fulfill it.

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