Demonstrators stand outside of the Governor’s Mansion in Jefferson City on July 1, 2021 and hold signs urging Gov. Mike Parson to fund voter-approved Medicaid expansion (Photo by Tessa Weinberg/Missouri Independent).
In the special session that ended Sept. 12, lawmakers approved measures that would block the ballot process that delivered medical marijuana, Medicaid expansion, reproductive care, and paid sick leave
Over the past two decades, Missouri’s broadest health reforms have come from the ballot box, not the Capitol. When the General Assembly did not act, voters legalized medical marijuana, expanded Medicaid, protected reproductive rights, and approved paid sick leave for workers who previously lacked it.
Each reform faced legislative resistance and saw its impact delayed or narrowed through lawsuits, refusals, and repeals.
In 2018, after years of inaction in Jefferson City, voters approved medical marijuana. Opponents immediately filed lawsuits, and the state slowed implementation by tightly restricting licenses. By 2020, only a small number of dispensaries were operational statewide, showing how legal delays restricted access even after voter approval. Only after the Missouri Supreme Court upheld the measure did the program move forward, illustrating the limits of voter-led policy without strong legislative follow-through.
Missouri voters approved Medicaid expansion for low-income adults in 2020, ending more than a decade of legislative resistance. Implementation did not begin until 2021, after the Missouri Supreme Court ordered the state to comply. Governor Parson and budget chair Cody Smith contended expansion would cost hundreds of millions annually and force cuts elsewhere.
They were wrong. Uncompensated hospital costs fell, patients paid less out-of-pocket, and federal matching funds eased pressure on the state budget. By 2022, emergency department visits covered by Medicaid rose about 15%, while visits by uninsured patients fell roughly 14%. The uninsured rate has dropped sharply over the past decade, with Medicaid expansion playing a major role once it took effect in 2021. Yet rural Missouri still lags behind, with higher uninsured rates and heavier reliance on Medicaid coverage than urban areas.
In 2024, a coalition led by Missourians for Healthy Families & Fair Wages gathered signatures for Proposition A. Voters approved the measure overwhelmingly, guaranteeing paid sick leave and a higher minimum wage for roughly 728,000 workers. Proposition A was upheld by the Missouri Supreme Court when business groups challenged it, but the legislature repealed the law in 2025, immediately leaving many workers vulnerable to lost wages and increased public health risks.
The same year, voters passed Amendment 3, restoring constitutional protections for abortion, contraception, and miscarriage care after Missouri’s near total ban in 2022.
Missouri is one of the most dangerous states in the nation to give birth. Over 40% of Missouri counties are maternity care deserts, and Black women die at four times the rate of white women. In a 2018 state mortality review, 82% of pregnancy-related deaths were found to be preventable, with Medicaid patients dying at four times the rate of mothers with private insurance — all before Missouri expanded Medicaid in 2021.
These numbers reflect lethal systemic inequities across Missouri, making timely prenatal and miscarriage care difficult to access. Amendment 3 removed legal barriers, allowing care earlier and reducing some of the risks created by limited local access.
In 2026, Missouri voters will be asked to repeal those protections while the state seeks to delay and complicate implementation.
Even with extensions to postpartum Medicaid coverage and modest increases to dental and provider reimbursement rates, many Missourians still face gaps in access. These are lawmaker-led reforms, incremental changes that improve some services but leave large portions of the population without meaningful coverage.
Voter-led initiatives, by contrast, have reshaped the state’s health landscape—expanding Medicaid, protecting reproductive rights, legalizing medical marijuana, and guaranteeing paid sick leave—delivering broad and tangible impacts that the legislature alone has repeatedly failed to achieve.
Missouri has repeatedly shown that voter-led reforms, paired with stronger transparency, accurate fiscal notes, and safeguards such as sunset clauses or dedicated revenue, can deliver real benefit.
The two measures passed in the special session would dismantle the process Missourians have relied on for two decades to pass reforms their representatives repeatedly blocked.
HJR 3 would require citizen-led initiatives to win not only a statewide majority but also in each of Missouri’s eight congressional districts, giving a single district the power to veto a measure for the entire state. This rule applies only to voter initiatives, not to measures lawmakers place on the ballot. HB 1 adds a new tactic by authorizing mid-decade redistricting, a rare move critics warn would allow politicians to redraw maps after seeing which areas supported or opposed a measure.
Together, these changes would have nullified past voter-approved reforms at the ballot box and made it far easier for lawmakers to overturn future initiatives, leaving Missourians without the protections and expanded access that citizen-led reforms have historically delivered.
In 2025, The Fairness Project tracked roughly 150 bills across 15 state legislatures that aimed to weaken ballot initiatives, nearly double the volume from two years earlier. In Missouri, the legislative majority has already added hurdles by stretching lawsuit timelines, titling ballot summaries, tightening donor rules, and even delaying an abortion measure under the former Attorney General’s office.
For Missourians, closing the ballot means shutting down the only proven path to major health reform in the past 20 years. Supporters of redistricting initiatives argue the process can be influenced by outside interests or lead to costly programs, but the record in Missouri shows otherwise: citizen-led reforms have consistently improved health in communities and strengthened the state.
The real risk is not in letting voters decide, but in silencing them.
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