Missouri voters will get another chance to register an opinion on a portion of President Barack Obama's health care law with a Nov. 6 ballot measure that would prohibit the governor from creating an online shopping site known as a health insurance exchange.
But much like Missouri's August 2010 referendum on an insurance mandate in Obama's health care law, the latest vote may carry more symbolism than substance.
No matter whether Proposition E passes or fails, federal law still requires health insurance exchanges to be established in every state by 2014.The exchanges are meant to provide individuals and small businesses a way to compare and buy health insurance policies online - like consumers already do with airline tickets and hotels. States can choose to set up their own online marketplace, work with the federal government, or let federal officials handle the whole thing themselves.
Thus the only issue before Missouri voters is whether the governor's administration can establish a state-run insurance exchange, or whether that authority must come from a legislatively or a voter-approved law.
Even then, the ballot measure may be largely symbolic. That's because both Democratic Gov. Jay Nixon and Republican challenger Dave Spence say they have no plans to establish a state-run exchange. The deadline for states to submit plans to the federal government is Nov. 16. So for all practical purposes, it may soon be too late for Missouri to develop its own insurance exchange, even if a governor wanted to do so.
State Sen. Rob Schaaf, who sponsored the ballot measure, said there is a broader principle at stake about who should make Missouri's major decisions.
"I want to make absolutely sure that everybody knows that an exchange cannot just be created by the one person, the governor," said Schaaf, R-St. Joseph.
"I know that some people claim that it's just simply political, but it's not," Schaaf added. "This is a true legislative vs. executive branch battle here. I think it's an important one, not symbolic."
Schaaf's ballot measure stems from a political showdown that happened on Sept. 15, 2011. At that time, Missouri already had received a $1 million federal planning grant and been awarded an additional $20.8 million to make further preparations for an insurance exchange. A state board was scheduled 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 learned at the last moment about the meeting and complained that Nixon's administration was attempting to implement an insurance exchange without legislative approval. That feeling of distrust led the Republican-led Legislature to refer the prohibitory measure to the November ballot.
Not only would the ballot measure bar the governor and his administration from taking steps to establish a state-run health insurance exchange, but it also would prohibit any state agency or employee from providing "assistance or resources of any kind" to the federal government to implement its own insurance exchange in Missouri, unless such actions were authorized by a state law or required by federal law.
Because it seems likely the federal government will have to run Missouri's insurance exchange, passage of the ballot measure could make that process more complicated, said Ryan Barker, director of health policy at the St. Louis-based Missouri Foundation for Health.
Barker said that when people sign up for private insurance coverage through a health exchange, the system is supposed to route them to the state's Medicaid program if they meet the eligibility criteria. That requires some technological cooperation with the state, he said.
If the ballot measure passes, "I think it makes state agencies, state workers, probably a little nervous to even have communication with the feds," Barker said. "It's going to make the implementation of an exchange a little more bumpy."
As of August, 15 states and the District of Columbia had established state-based health insurance exchanges, including three - Kentucky, New York and Rhode Island - that did so through gubernatorial orders, according to the Kaiser Family Foundation, which has analyzed and tracked the implementation of the federal health care law.
States that run their own insurance exchanges can control which health plans participate, determine the role for insurance agents and oversee the outreach to consumers, among other things, said Jennifer Tolbert, the Kaiser foundation's state health reform director. Yet even with federal grants, states could incur costs from the time and resources it takes for their employees to oversee the insurance exchanges, she said.
Missouri is the only state to put a specific question about health insurance exchanges to a statewide vote, according to the National Conference of State Legislatures. But voters in four other states - Alabama, Florida, Montana and Wyoming - will be deciding November ballot measures that take a more general stance in opposition to the federal health care law.
In August 2010, Missouri voters became the first in the nation to pass a ballot measure that intentionally conflicted with a key part of Obama's health care law. That Missouri law prohibits governments from requiring people to have health insurance - in direct contrast with a federal mandate that most Americans have health insurance by 2014 or face tax penalties. The Missouri measure passed with 71 percent of the vote.