For a century Missouri was a bellwether state in presidential elections, always picking the winner. Since 2008 it has been experiencing a partisan divide along urban/rural lines with President Obama losing the state twice. The battle over Medicaid expansion found a Democratic governor unable to convince a Republican legislative majority to support ACA-based expansion. The more highly partisan legislative environment has rendered traditional bargaining and negotiations impossible on the controversial question of Medicaid expansion.

Despite supportive advocacy by hospitals and the business community, the Republican legislative leaders have opposed any movement on Medicaid expansion over the past four years. There will be a new occupant in the governor's mansion in 2017, which may create a fork in the road. Democrats are unlikely to regain a legislative majority, and one path is continued Republican refusal to consider expansion. The other path features the new governor responding to the national 2016 election outcome, and creating the prospects for a deal, perhaps around a waiver plan.

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