Healthcare for Missouri, the sponsor of the Missouri Medicaid Expansion Initiative, was the only campaign targeting the Missouri 2020 ballot to submit signatures by the May 3 deadline. The campaign reported submitting over 350,000 signatures to the Missouri Secretary of State. A total of 160,199 valid signatures are required to make the ballot.

The Medicaid Expansion Initiative would amend the Missouri Constitution to require the state government to provide Medicaid for persons whose income is 133 percent of the federal poverty level or below and who are not eligible for other state insurance coverage, which would effectively increase the coverage level to 138 percent under the provisions of the Affordable Care Act.

Medicaid is a government program that provides medical insurance to groups of low-income people and individuals with disabilities. The Affordable Care Act (ACA), also known as Obamacare, provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level. In 2012, the U.S. Supreme Court ruled in NFIB v. Sebelius that the federal government could not withhold funds from states that refused to expand Medicaid. The ruling had the practical effect of making Medicaid expansion optional for states. As of January 2020, a total of 36 states and Washington, D.C., had expanded or voted to expand Medicaid, while 14 states had not.

In Missouri, the signature requirement totals for initiatives are based on the number of votes cast for governor in the state’s most recent gubernatorial election. In two-thirds of Missouri’s congressional districts, proponents must collect signatures equal to 5 percent of the gubernatorial vote for initiated state statutes and veto referendums and 8 percent of the gubernatorial vote for initiated constitutional amendments. Therefore, the total number of signatures required is less than 5 percent or 8 percent of the total votes cast for governor. For 2020, petitioners needed to collect at least 160,199 valid signatures for initiated constitutional amendments and at least 100,126 valid signatures for initiated state statutes and veto referendums.

There is one legislatively referred constitutional amendment certified for the November ballot in Missouri. The State Executive Term Limits Amendment would limit the lieutenant governor, secretary of state, state auditor, and attorney general, along with the governor and state treasurer, to two terms of office. In Missouri, the state legislature can refer state statutes and constitutional amendments to the ballot for voter consideration during its legislative session. The 2020 legislative session was scheduled to convene on January 8, 2020, and adjourn on May 15, 2020.

A total of 82 measures appeared on statewide ballots in Missouri from 1996 to 2018. About 63 percent (52 of 82) of the total number of measures that appeared on Missouri ballots were approved, and about 37 percent (30 of 82) were defeated. Between 1996 and 2018, an average of seven measures appeared on the ballot in Missouri during even-numbered election years.