In a ballot-measure vote Tuesday, Missourians will make a yes-or-no choice on a central plank of the reforms signed into law by President Obama earlier this year – a mandate that individuals who don't have health insurance must purchase it.
The vote presents what some political analysts say is the first moment when voters in any state will take what amounts to referendum on Mr. Obama's approach to health-care reform. "Proposition C," if passed, would ban enforcement of the individual mandate within Missouri.
It won't represent a scientific sampling of public opinion in the "Show-me State," which is often a closely-fought swing state in presidential elections. (The vote comes on a primary election day, when turnout is often light, especially among voters not closely attached to a party.) And the anti-Obama measure, if passed, would have an uphill battle in court.
But its passage would add to a perception that the medical-insurance reforms face significant opposition, which hasn't died down just because the ink has dried on a presidential signature.
Tuesday's vote comes as national polls show weak support for the reforms, as Republicans are seeking to leverage the issue to their advantage in fall congressional elections, and as some other states are preparing to take similar symbolic votes on the Obama reforms this fall.
A July CBS News poll found only 36 percent of Americans say they approve of the health reforms, versus 49 percent who say they disapprove. Another July survey, the TIPP poll by Technometrica Market Intelligence, found 41 percent support the law and 45 percent disapprove. Some 51 percent of independent voters oppose the law, the poll found.
Last week, Democrats in Congress sought to amend one portion of the reform law that has rankled small employers. A rule would require extra paperwork from firms when they buy more than $600 in goods and services from a vendor in a year.
But Republicans complained that this proposal, called the "small business tax relief act," would be paid for by tightening taxes on firms with global operations. The change needed two-thirds support in the house, and failed to win the Republican support needed to clear that hurdle.
“It’s one step forward, two steps back for Washington Democrats," House minority leader Rep. John Boehner (R) of Ohio said in a statement Friday. He said removing the burden on small employers would help, but that "the last thing we need right now is a tax hike that will destroy more American jobs."
Democrats argued that the tax change would help create jobs by reducing tax incentives for employers to move jobs overseas.
It's an example of the way elements of the mammoth reform law could be revisited and revised in the next few years, as key provisions begin to kick in.
The mandate on individuals to buy insurance, the focus in Missouri, is designed to resolve the so-called "free rider" problem, in which some individuals don't pay for insurance but end up using medical services when an emergency arises. Those costs end up pushing insurance prices up for others.
But in Massachusetts, a state that already has such a mandate, the effort to solve that problem has not tamed the pace of medical inflation.