Voters in four states approved measures prohibiting the enactment of some provisions of the Affordable Care Act (P.L. 111-148 and P.L. 111-152). Voters in Montana adopted a referendum and voters in Alabama and Wyoming adopted constitutional amendments to make it unconstitutional to tax the residents of their state for not having health insurance and making it illegal to let someone directly pay for health care. In Missouri voters prohibited the institution of an insurance exchange unless the legislature votes to authorize one.
In Montana nearly 69 percent of the voters adopted a referendum prohibiting the “federal government from requiring the purchase of health insurance or imposing any penalty, tax, fee or fine on those who do not purchase health insurance,” according to Legislative Referendum No. 122. This referendum becomes law and is effective on January 1, 2013. The referendum received 275,301 votes in its favor, and 136,551 votes against it.
Alabama voters approved a constitutional amendment that prohibits the assessment of any penalties or fines for paying for health care services. Statewide Amendment 6 was designed to prevent mandatory participation in any health care system. Specifically it prohibits the payment of a fine or penalty by individuals who pay cash for health care services. The Supreme Court ruled that the amount a person would have to pay for not having health insurance is a tax and not a fine or penalty. Secondly, this amendment applies only to individuals who pay cash for health care services. This amendment was approved by 59 percent of the voters with 833,262 people voting for the amendment and 576,177 or 41 percent voting against the amendment.
In Wyoming voters adopted a constitutional amendment that makes it a right to directly pay for health care. The amendment prohibits the imposition of penalties or fines for the direct payment of health care services. Constitutional Amendment A requires the state to act to preserve these rights from undue government influence. Finally, the legislature is permitted “to place reasonable and necessary restrictions on health care consistent with the purposes of the Wyoming Constitution.” This amendment was approved by 180,289 voters and rejected by 53,919 voters.
In Missouri voters adopted a proposition that requires the legislature to approve of activities by state officials and agencies before they begin work on developing insurance exchanges. Proposition E was designed to prevent the governor from issuing an executive order to establish an insurance exchange. This proposition received 1.5 million votes, or 61 percent of the vote, and 970,000 voters, or 38 percent, voted against Proposition E. States that choose to operate their own insurance exchange under the ACA are required to have an operating insurance exchange by January 1, 2014.