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MO Health Exchange Referendum - Prop E
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This Discussion Guide is part of Community Conversations at FOCUS St. Louis.  It is meant to initiate civil discourse around the policies that affect the St. Louis region; to hear each other’s perspective. As is the case with all public policies, this issue is complex and multi-faceted, with many stakeholders. Please keep this in mind as you discuss the Missouri Health Exchange Referendum in your community.

Missouri Health Exchange Referendum – 2012 Ballot Proposition E
In 2010, the Congress of the United States passed, and the President signed, the Affordable Care Act (ACA), which has also been dubbed "Obamacare.” The law is complex and affects many aspects of health care insurance nationwide.

One important provision of the law is that every state is mandated to establish a health insurance exchange. In the event that a state does not establish its own health care exchange by 2014, the Federal Government is authorized to step in.

The Missouri General Assembly placed a referendum on the November ballot that asks:

 "Shall Missouri Law be amended to prohibit the Governor, or any state agency, from establishing or operating state-based health insurance exchanges unless authorized by a vote of the people or by the legislature?”

Note that the referendum does not prohibit the establishment of a state-based health insurance exchange. Rather, it requires that such an exchange must be voted upon by either the General Assembly or by a vote of the people.


Legislation establishing a state-based health insurance exchange failed in both the 2012 and 2011 legislative sessions. In June 2011, the Senate had created the Senate Interim Committee on Health Insurance Exchanges to explore Missouri’s options to establish a state-based exchange. 
In the absence of exchange legislation, Missouri’s Health Insurance Exchange Coordinating Council, initially established by the Governor to coordinate the state’s response to federal health reform, moved forward with exchange planning.

The legislation passed by the General Assembly in May 2012 created a ballot measure seeking voters’ input on whether the state can establish a state-based health insurance exchange without approval from the Legislature; such a measure could prevent Governor Jay Nixon (D) from establishing an exchange via Executive Order.

From the Kaiser Family Foundation:

Exchanges are new organizations that will be set up to create a more organized and competitive market for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options.

Beginning in 2014, Exchanges will serve primarily individuals buying insurance on their own and small businesses with up to 100 employees, though states can choose to include larger employers in the future. States are expected to establish Exchanges--which can be a government agency or a non-profit organization--with the federal government stepping in if a state does not set them up. States can create multiple Exchanges, so long as only one serves each geographic area, and can work together to form regional Exchanges. The federal government will offer technical assistance to help states set up Exchanges.

Proponents of Proposition E note that the proposition does not make exchanges illegal, but simply requires a vote of the people or, more likely, legislative action in order to establish such an exchange. The expressed intent is to ensure that the exchanges reflect overall Missouri values, and are not established by the Executive Branch with no outside input.

Who else is involved with this issue?

In many ways, this is a partisan issue, with Republicans largely supporting Proposition E and Democrats opposing it. The proposal was placed on the ballot by the Republican-controlled General Assembly, largely along party-line votes. As well, the original wording of the ballot, written by Democratic Secretary of State Robin Carnahan, was successfully challenged by Republican Lieutenant Governor Peter Kinder. Republican candidate for Governor Dave Spence has encouraged supporters to vote for Prop E.
The State of Missouri has turned down substantial Federal support for establishing exchanges. From, a story in the St. Louis Beacon:

So far, Missouri has rejected nearly all federal funding for exchanges. It initially got a $1 million planning grant and was eligible for, but never accepted, another $20.8 million for building a portal for its exchange system. Nor did it take another $50 million in April to help the state upgrade its Medicaid information technology system. Some lawmakers objected to the $50 million grant because they said upgrading the technology was part of building an exchange.

Three Possible Perspectives:

Person A believes that the Affordable Care Act is an encroachment by the Federal Government into health care markets. State-based health care exchanges are an important component of ACA, and passage of Proposition E would postpone implementation of the ACA, hopefully allowing it to be overturned at the national level.

Person B favors the Affordable Care Act, believing that the ACA will help lower overall health care costs in the long run, and help cover uninsured Americans. Anything that delays implementation of ACA should be defeated, including Proposition E

Person C opposed the Affordable Care Act, but is concerned that the Federal government in 2014 is authorized to establish a health exchange in any state that hasn’t already established one. Proposition E would likely result in the Federal government establishing such an exchange in Missouri, and person C would rather have Missourians creating this exchange rather than some federal bureaucrat.  
Discussion Questions:
  1.  How do you feel about "Obamacare?” Overall, do you think the act will accomplish its twin goals of making health care more accessible, and at the same time help lower costs (or cause the growth of health care costs to slow down)?
  2. Do you fear that Missouri will miss out on getting its share of federal funds or is the idea of a health care exchange just an example of too much federal intrusion?
  3. What are the alternatives to health care exchanges that perhaps should be considered?
  4. How might a health care exchange benefit you, your friends or family members?
Links for further reading:
  1. Missouri Foundation for Health: Proposition E Summary: Health Insurance Exchange in Missouri
  2. Ballot*Pedia – General information about proposal
  3. Missouri General Assembly - SB 464 - Legislation Placing Prop E on the ballot
  4. HealthCare.Gov: "What is the Health Insurance Marketplace” 
  5. Kaiser Family Foundation: Health Facts for the State of Missouri
  6. Kaiser Family Foundation: Health Reform
  7. August 28, 2012 Kansas City Star Midwest Democracy article: Judge strikes down Missouri health exchange ballot summary
  8. October 19, 2012 St. Louis Beacon article: Proposition E would require popular or legislative approval for insurance exchange
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