Missouri voters reject federal insurance mandate

Missouri voters overwhelmingly approved a ballot initiative rejecting a key part of the national health reform law, while a Florida judge prevented a state constitutional amendment with similar intentions from reaching the ballot box because of confusing wording.

Few legal experts consider the state proposals more than symbolic, as federal law generally trumps state law. But lawsuits filed or joined by officials in 21 states challenging the federal government's authority to require health insurance have the potential to overturn the federal law.

Just over 71% of Missouri voters on Aug. 3 approved an initiative rejecting the national health reform law's insurance coverage mandate, while 29% voted against it. More than 940,000 Missourians voted. The federal law requires nearly all U.S. residents to have health coverage by 2014 or pay a tax penalty.

The Missouri referendum asks voters in part if they want to "deny the [federal] government authority to penalize citizens for refusing to purchase private health insurance or infringe upon the right to offer or accept direct payment for lawful health care services."

Support for the Missouri referendum may have been boosted by high Republican turnout due to interest in local races, said C.C. Swarens, executive vice president of the Missouri State Medical Assn., which supported the referendum. However, the margin of victory was so overwhelming that the referendum must have had bipartisan support, he said.

The state medical society supported the referendum because the national law doesn't address medical liability reform, nor does it prevent the Medicare physician pay cuts required by the sustainable growth rate formula, Swarens said. Instead, he said the federal law creates more regulatory burdens for small businesses and spends too much money.

Republicans in Washington, D.C., characterized the results as an indication that the Obama administration was facing wide dissatisfaction with the national health reform law. "The people of Missouri have sent a message to Washington: Enough is enough," said Senate Minority Leader Mitch McConnell (R, Ky.).

However, the percentage of people in July who viewed the health reform law favorably reached 50%, an increase of two percentage points from the previous month, according to the Kaiser Health Tracking Poll, released on July 29. Opposition to the law was at 35%, down from 41%, while the percentage of people who did not know increased to 14%, up four percentage points.

Leon County Circuit Judge James O. Shelfer ruled on July 30 that a Florida constitutional amendment to block local implementation of the national health reform law was too poorly worded for the November ballot. Shelfer ruled that the proposal was confusing because it sought to "ensure access to health care services without waiting lists" and to "protect the doctor-patient relationship" but did not explain how it would achieve these and other goals. Four Florida citizens filed the lawsuit challenging the amendment.

The Florida Medical Assn. had endorsed the amendment in part because Floridians deserve "the opportunity to make their own health care choices, and this amendment will protect that fundamental right," said FMA President James B. Dolan, MD.