No matter whether the federal health care law stands or falls before the U.S. Supreme Court, Missouri voters will get to register their opinions this November on whether the governor should be allowed to set up an online marketplace for patients to shop for insurance policies.
It will be the second time in two years that Missourians may cast a largely symbolic vote related to the health care law signed by President Barack Obama.
In August 2010, Missouri became the first state to officially snub the new federal law through a referendum when 71 percent of voters approved a proposition barring the government from requiring people to have health insurance. The Missouri law set up a direct conflict with a federal provision requiring most people to have health insurance by 2014 or face penalties. However, it was considered largely symbolic because federal laws generally trump state laws.
The insurance mandate is at the center of a legal challenge expected to be decided today by the U.S. Supreme Court in a case brought by attorneys general in about half the states. The Supreme Court could strike down the entire law, uphold it or issue a mixed ruling invalidating some portions - such as the insurance mandate - while allowing other provisions to stand.
At issue for Missouri voters this November will be one of those other provisions in the federal law: a requirement for states to create a health insurance exchange by 2014 or have the federal government run one for them. The insurance exchanges are meant to provide individuals and small businesses a way to compare and buy health insurance policies online - sort of like what already exists for airline tickets and hotel rooms. Missouri had about 835,000 uninsured residents in 2010, about 14 percent of the population, according to the U.S. Census Bureau.
The Missouri ballot measure would allow a state-created insurance exchange only if it is specifically authorized by a state law or a subsequent vote of the people. It would prohibit the governor or any executive branch officials from taking any steps toward establishing an exchange on their own.
If the Supreme Court strikes down the requirement for health insurance exchanges, Missouri's upcoming vote "becomes much less important," acknowledges state Sen. Rob Schaaf, R-St. Joseph, a family physician who sponsored the ballot measure.
But even if the federal law is upheld, Missouri's vote may be largely symbolic.
That's because Nixon's administration has halted efforts to lay the groundwork of an insurance exchange, and it may be too late for Missouri to do so after the Nov. 6 election. States face a Nov. 16 deadline to submit plans for health insurance exchanges to the U.S. Department of Health and Human Services.
The Legislature is not in regular session again until January, and Nixon has said he won't use an executive order to create an exchange without legislative approval.
At one point, however, it appeared Missouri was on a path toward setting up an exchange.
The state received a $1 million planning grant and was awarded a $20.8 million federal grant to make further preparations for an insurance exchange.
A state board was scheduled last September to allocate a portion of that money for consultants to work on the technical aspects of an insurance exchange. But the board vote was canceled - and never rescheduled - after Schaaf and several other Republican state senators complained that Nixon's administration was attempting to implement an insurance exchange without legislative approval. That feeling of distrust led lawmakers to refer the prohibitory measure to the November ballot.
If the state must have an insurance exchange, Schaaf said he would prefer to let the federal government run it - partly, to save the state money.
State Rep. Chris Molendorp, a Republican who runs an insurance agency in Raymore, had sponsored legislation in 2011 that would have created a state-run insurance exchange. It passed the House but died in the Senate under opposition from some Republicans who didn't want to pass anything that could be viewed as endorsing Obama's health care law.
If the Supreme Court upholds the requirement for health insurance exchanges, Molendorp hopes Missouri lawmakers could rush a bill to passage in January and persuade the federal government to accept a state-based plan - even though it would be past the application deadline. He said there's no guarantee that a federally run insurance exchange would "preserve the uniqueness of our marketplace" or allow people to purchase the policies through local insurance agents instead of online or over a toll-free telephone number.
"I'm trying to be the grown-up about this," Molendorp said. "I understand that the majority of Missourians are not supportive of the health care law, but if the Supreme Court on Thursday upholds it, other than secession, what is my choice?"