(CNN) Missouri residents voted Tuesday to expand Medicaid to low-income residents by 53% to 47%, becoming the sixth state to do so at the ballot box, CNN projects.
The ballot measure called for enshrining Medicaid expansion in the deep red state's constitution, which makes it harder for legislators to throw up hurdles to enrollment, such as work requirements. The Trump administration and many Republican state officials have sought to add work requirements, premiums and other mandates to Medicaid, which make it more difficult for folks to qualify for coverage.
The passage also marks yet another defeat in President Donald Trump's quest to dismantle the Affordable Care Act, which authorized the safety net program's expansion to all adults with incomes below 138% of the poverty level, or about $17,600 this year. The President handily won Missouri in 2016.
An estimated 230,000 residents -- who earn less than roughly $18,000 a year -- are expected to gain coverage. Currently, childless adults aren't eligible for Medicaid, and neither are parents with incomes greater than roughly $4,800 a year for a family of four, according to a report from the State Auditor's Office.
Missouri, however, is expected to have to kick in at least $200 million a year -- states have to shoulder 10% of the cost, with the federal government picking up the rest.
The initiative began long before the coronavirus pandemic but took on increased urgency amid the outbreak. Supporters sought to tie the ballot measure to the renewed focus on health care coverage and access.
Medicaid expansion should be a boon to the state's hospitals, decreasing the number of uninsured patients they treat and funneling more than $1 billion in federal funds to the state annually. Some 15 hospitals, including 10 rural institutions, have closed since 2014.
"Not only was the lack of expansion hurting our health care systems and our health care coverage here in Missouri, but it's starting to really take a toll on our economy," said Jack Cardetti, spokesman for the Yes on 2:Healthcare for Missouri campaign, noting that hospitals create many jobs.
Volunteers raised awareness of the ballot initiative, which garnered nearly twice as many signatures as needed, and a retired ambulance made stops across the state to urge residents to approve the measure. It was also supported by the state Chamber of Commerce, among other groups.
But the effort has also attracted opponents, including Republican Gov. Mike Parson, the state chapter of Americans for Prosperity and United for Missouri, a grassroots organization that advocates for limited government.
Parson maintains that Missouri cannot afford to expand, a spokeswoman said. Medicaid already makes up 24% of the state's general revenues, and enrollment has grown during the pandemic.
Medicaid costs can quickly balloon, said Carl Bearden, CEO of United for Missouri and former chair of the state House Budget Committee.
"Even in good years, it's tough to come up with," he said, adding that the state recently had to cut $700 million from its budget as the pandemic cut into tax revenues.
Missouri is the sixth state run by Republicans to say yes to expansion, a provision of the Affordable Care Act, at the ballot box.
Oklahoma voters narrowly approved expansion in June. Maine was the first, in 2017, followed by Nebraska, Utah and Idaho a year later.
"Politicians who fail to heed the voters' message on health care are going to be in trouble this November," said Jonathan Schleifer, executive director of The Fairness Project, which has helped organize the ballot campaigns. "Two red states, that Trump won by double digits in 2016, just sent the largest possible rebuke to the President's attacks on the Affordable Care Act."
Still, in all of the efforts prior to this year, elected officials delayed implementation or attempted to add restrictions to the program. Medicaid expansion recently began in Nebraska, and tens of thousands of people have enrolled in each of the other states.
Advocates have their eyes on Florida and, possibly, Mississippi, Wyoming and South Dakota, for 2022, Schleifer said.
Some 13 states, all with either Republican governors or GOP-led legislatures, have yet to adopt Medicaid expansion, which began in 2014. More than 2 million Americans fall into this so-called coverage gap, according to the Kaiser Family Foundation.
This story has been updated with the election results.