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Nika Cotton opened her own shop, Soulcentricitea, just weeks ago. When public schools shut down in the spring, Cotton had no one to watch her young children, who are 8 and 10. So she quit her job in social work 鈥� and lost her health insurance 鈥� in order to start her business. (Alex Smith/KCUR)

Despite strong opposition from Republicans and rural voters, Missouri on Tuesday in expanding its Medicaid program. Voters in Missouri approved creating a state constitutional amendment that will open Medicaid eligibility to include healthy adults starting July 1, 2021.

Voters approved expansion by a margin of 6.5 percentage points.

Missouri joins five other mostly conservative states that have passed Medicaid expansion via ballot initiatives 鈥� most recently, Oklahoma, . Most of the remaining 12 states that have not expanded Medicaid are Republican-leaning states in the South.

Nika Cotton, owner of Soulcentricitea, a new tea shop in Kansas City, Missouri, woke to the news on Wednesday morning. Cotton, whose children are 8 and 10, said she will qualify for health care coverage under the expansion.

鈥淚t takes a lot of stress off of my shoulders with having to think about how I鈥檓 going to take care of myself, how I鈥檓 going to be able to go and see a doctor and get the health care I need while I鈥檓 starting my business,鈥� Cotton said.

Medicaid expansion, which states have the option of adopting as part of the Affordable Care Act, extends eligibility in the program to individuals and families with incomes up to 138% of the federal poverty level. A family of three, like Cotton鈥檚, could make up to $29,974 to qualify.

The federal government pays for 90% of expansion costs.

As of 2018, 9.3% of Missourians were uninsured. And in 2019, researchers from Washington University in St. Louis estimated that around 230,000 people in Missouri would enroll for Medicaid if it were expanded. The study also showed expansion would save the state an estimated $39 million a year, largely by eliminating the need for other state health spending.

Missouri鈥檚 adoption of expansion follows a trend of increasing support in largely Republican states, according to health policy expert of the Commonwealth Fund.

鈥淲hat we鈥檝e seen in our surveys over the years is when you take the labels off of the policies, when you take the Affordable Care Act label off, when you take Medicaid expansion off, and just start asking people whether or not you think low-income families should have access to Medicaid coverage, the support is overwhelming,鈥� Nuzum said.

Support for expansion came largely from voters in and around Missouri鈥檚 urban centers such as Kansas City, St. Louis, Springfield and Columbia. In Kansas City for example, 87.6% of voters backed the measure.

Amendment 2 was rejected overwhelmingly by conservative voters in the mostly rural parts of the state that have the highest uninsured and poverty rates. Voters in McDonald, Morgan and Scotland counties, which have the three highest uninsured rates in the state, rejected the measure by margins of nearly 2-to-1 or greater.

Expansion opponents warned that high enrollment in the program could lead to the state鈥檚 10% share of the costs becoming a significant burden for Missouri, especially when state revenues are down.

鈥淲hen state revenues fall, it begs the question, how are you going to pay for this?鈥� said Ryan Johnson, in late July. He is a senior adviser for , a conservative policy advocacy organization.

鈥淲e鈥檙e concerned that they are going to have to raid public education,鈥� he said, 鈥渁nd that鈥檚 a disservice to the kiddos who hope to go back to school this fall, the teachers, the administrators and everyone involved in the public education system.鈥�

Responding to declining revenue related to the coronavirus, Missouri鈥檚 Republican governor, Mike Parson, recently reduced the 2021 budget by nearly $449 million, with education taking the hardest hit.

Health care experts have said that the economic effects of the pandemic, including high unemployment and lower state revenue, could strain the capacity of state Medicaid programs. However, health care advocates argue that expansion benefits individuals and families struggling as a result of the pandemic, and the influx of federal dollars and the jobs that result from expansion could help the economy.

鈥淚f we鈥檙e worried about the economy and we鈥檙e worried about people working, Medicaid expansion is actually a way to encourage people to work and not have that worry they鈥檙e going to lose health insurance for themselves or their families,鈥� said Ryan Barker, vice president of strategic initiatives for Missouri Foundation for Health.

Republican state lawmakers have fiercely resisted Medicaid expansion. The expansion question was placed on the ballot after a petition.

Expansion advocates enlisted the Fairness Project, a Washington, D.C.-based campaigning organization, in developing and executing their campaign strategy. The Fairness Project has been involved in successful Medicaid expansion campaigns in other mostly conservative states, including Maine, Utah, Idaho, Nebraska and Oklahoma.

The 鈥� was supported by a wide range of groups, including the Missouri Chamber of Commerce and Industry, the Missouri Hospital Association, the NAACP, the AFL-CIO and the AARP, among others. And, the coalition forged unlikely alliances, including Planned Parenthood supporters and Catholic Charities of St. Louis, which is operated by the Archdiocese of St. Louis.

YES on 2 campaign material made almost no mention of the Affordable Care Act, which has been unpopular in Missouri, and some of its flyers didn鈥檛 use the words 鈥淢edicaid expansion.鈥�

Although support for the measure was much lower in conservative rural areas, Fairness Project executive director said Missouri鈥檚 expansion success relied on both activating progressive urban voters and engaging rural voters 鈥� though conservative resistance remained a significant obstacle to reforming health care policy.

鈥淚 think there鈥檚 still a lot of work to do to push back against the hundreds of millions of dollars, the public messages coming from as high as the White House, that there鈥檚 something wrong with the Affordable Care Act,鈥� Schleifer said.

Opponents to expansion included Gov. Parson and other Republican lawmakers, Missouri Right to Life, Missouri Farm Bureau and Americans for Prosperity.

In the days leading up to the election, the 鈥淣o on 2 in August鈥� campaign sent a mailer suggesting that expansion would lead to an influx of undocumented immigrants seeking health care, but undocumented immigrants are not eligible for Medicaid and would not be under expansion, either.

The flyer, which featured a man in a medical mask emblazoned with the Mexican flag, read 鈥淎mendment 2 Means Illegal Immigrants Flooding Missouri Hospitals 鈥� While We Pay for It!鈥�

The 鈥淣o On 2 in August鈥� campaign did not respond to requests for comment about the flyer.

Between serving customers on a busy morning on Wednesday, shop owner Cotton said her excitement about expansion was only slightly diminished by having to wait almost a year for it to take effect.

鈥淚t鈥檚 better late than never,鈥� said Cotton. 鈥淭he fact that it鈥檚 coming is better than nothing.鈥�

This story is part of a partnership that includes , and Kaiser Health News.