Did Missouri pass Medicaid expansion thanks to its rural counties — or in spite of them?
And can the answer tell us something about Democrats’ electoral fortunes in the state moving forward?
On Tuesday night, Missouri became the latest state in which voters expanded Medicaid under the Affordable Care Act after their Republican-controlled state government refused to do so. For those who follow Missouri politics, the map at the end of the night showing support versus opposition to the measure — Amendment 2 — looked very familiar: the liberal option on the ballot (in this case, a ‘yes’ vote) received majority support from counties near the state’s major population hubs of Kansas City, St. Louis, Columbia, and Springfield, while majorities in every rural county voted for the conservative ballot option (in this case, a ‘no’ vote).
At first glance, the story of the night appears to be that the state’s urban and suburban areas carried the referendum to a successful finish — this, despite the fact that the policy in question would, ironically, disproportionately benefit rural communities. However, a graphic recently making its way around social media by the group Physicians for a National Health Program (PNHP) tells a slightly different story: were it not for higher-than-normal support from rural counties for the liberal ballot option, Amendment 2 would not have passed.
Now, spend two seconds thinking about their argument and it falls apart. In their telling, Amendment 2 fails if all rural voters had voted no — and they’re right about that. However, there is no realistic scenario under which every single voter in a rural county would have cast a ‘no’ vote, which makes it difficult to gauge the validity of the underlying argument that rural voters played a pivotal role in securing the amendment’s passage.
Still, it’s possible that, at the margins, slightly stronger-than-average support in rural areas for the liberal ballot option may have given Amendment 2 the boost it needed to succeed. This is certainly a point worth considering, as Democrats in Missouri have had an increasingly difficult time winning statewide, which has corresponded with lower vote totals in rural parts of the state. And, if it’s true that higher relative support from rural counties led to the success of the amendment, that may be important information for Democrats to consider as they look for a path back to power in the state.
So, rather than posing a counterfactual in which all rural Missourians opposed the measure, a better test would be to ask what the outcome of the statewide vote would have been if these counties had supported Amendment 2 at a slightly lower rate — perhaps closer to a rate at which they have supported other liberal ballot options in recent elections, such as Democratic candidates.
An obvious choice for this comparison is the 2018 U.S. Senate race, which included Democratic incumbent Claire McCaskill and Republican challenger Josh Hawley. This example is instructive because McCaskill ultimately lost her bid for re-election, and part of the reason for this is that she only won 4 counties (plus the City of St. Louis). While they were based around the state’s liberal population centers, there simply were not enough votes in them to offset her dismal performance in the more conservative exurban and rural counties.
The starkest difference between McCaskill’s 2018 map and the Amendment 2 map further up is that Platte (suburban KC), St. Charles (suburban STL), and Greene (Springfield) Counties all backed Amendment 2, despite voting for the conservative ballot option (Hawley) in 2018. But were those three counties enough to tip the scales this time around? Is it possible that higher-than-normal margins in rural counties helped push Amendment 2 across the finish line, even if they didn’t support the measure by outright majorities?
To determine this, I took each rural county that voted against Amendment 2 and substituted in McCaskill’s (lower) vote shares. This allows us to see whether Platte, St. Charles, and Greene’s flips were enough — or whether slightly lower levels of support from rural Missouri would have doomed the amendment.
First, here is how the Amendment 2 vote broke down:
On the Amendment 2 vote, 35.0% of voters in rural counties voted ‘yes’ while 65.0% voted ‘no.’
And here is how the 2018 Senate vote broke down:
McCaskill only received 30.7% of the vote in those rural counties, trailing the ‘yes’ vote on Amendment 2 by 4.3 points. (And Hawley earned 67.5%, outpacing the ‘no’ vote by 2.5 points.)
So, if we substitute McCaskill and Hawley’s percentages in the place of the Amendment 2 percentages only in the state’s rural counties, here is what the final vote would have looked like for Medicaid expansion:
What this shows is that even if rural counties had supported Amendment 2 at the rates at which they might normally support the liberal option on the ballot, the amendment still would have passed, albeit by a smaller margin (51.3–47.9%). This indicates that the real power behind the ballot measure’s success came from the 3 suburban counties that flipped from right to left between 2018 and 2020.
Why is this worth sorting out? As previously noted, Democrats in Missouri have been pushed out of power at the statewide level in recent years — while they held nearly every statewide elected office 5 years ago, they control just one today. And, whereas, they used to be able to count on winning at least a handful, if not dozens, of rural counties, their power in those parts of the state has all but vanished — a microcosm of a trend across the country.
So, while Democrats determine the best way to rebuild their appeal in rural Missouri, the Amendment 2 results give them a very clear path back to power: win the state’s four major population centers and their suburbs, while still trying to hold rural losses to a minimum — something that, notably, the party’s 2020 gubernatorial nominee successfully did just 2 years ago.