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Voters will decide during the Aug. 4 primary election whether to expand Medicaid coverage in Missouri to adults with incomes up to 138 percent of the poverty level.

To date, 36 states and the District of Columbia have expanded Medicaid. Oklahoma became the latest state to expand Medicaid on June 30, when voters passed a ballot measure with a narrow 6,000-vote margin.

Expansion is part of the Affordable Care Act, also known as Obamacare. Originally, states were not given a choice whether to participate in expansion. However, a 2012 federal court decision said the U.S. government could not make participation mandatory. So, as an incentive for participation, the federal government pays 90 percent of the cost for people who qualify under expansion.

In 2019, a grassroots coalition of expansion backers began an initiative process and collected enough signatures to get the issue on a ballot by May 3 this year.

Missouri Gov. Mike Parson scheduled a vote on the issue, known as Amendment 2, to the Aug. 4 primary election, avoiding the anticipated high-turnout November general election.

In Missouri, the state's Medicaid program is called MO HealthNet. It serves about 900,000 people.

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Expansion would add about 230,000 adults to the program. It cost $10.3 billion in Missouri in 2018. The program was 24 percent of the state's general revenue and growing, according to Todd Richardson, former speaker of the Missouri House, whom Parson selected to direct the program late in 2018. (It was only 17 percent of the state's general revenue when Richardson first became a House member in 2009.)

A fiscal note received by the state House Budget Committee this summer said there is a possible range in cost to expand from an annual expenditure of $200 million to a savings of $1 billion.

If passed, the state Department of Social Services and MO HealthNet will be required to submit documentation to the U.S. Department of Health and Senior Services, Centers for Medicare and Medicaid Services.

"No greater or additional burdens or restrictions on eligibility or enrollment standards, methodologies, or practices shall be imposed on persons eligible for MO HealthNet services pursuant to this section than on any other population eligible for medical assistance," the amendment states.

President Lyndon Johnson, in 1965, signed Medicare and Medicaid into law in Independence, hometown of former President Harry Truman, who was present and became the first Medicare enrollee. The Medicaid program — originally intended to provide health care for Missouri's aging and vulnerable populations — has grown and changed since its beginning.

Shortly after it started, Congress limited — by income — who could enroll. Expansion of Social Security added to the rolls in 1972. Congress added poor children to Medicaid in 1997.

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