Missouri #Prop2 passed on the strength of overwhelming urban and moderate suburban margins. The rural margins for "No" were not large enough to overcome that.

The reasons behind this divide initially appear to be rural folks voting against their own economic self-interest. 1/

If rural hospitals are given a lifeline in the form of incremental reimbursement, where previously they were providing a ton of charity care, does this not benefit the communities these hospitals serve (and employ in)? 2/

As a purely economic argument, yes. However, this argument runs up against several competing moral and political arguments, and this contributes to the rural results seen last night.
Some observations from growing up in rural MO and IN, if you'll allow me:
3/

First, poverty in rural and exurban areas is easier to ignore. It's more spread out, and the average citizen is not forced to confront the conditions that their neighbors live in on a daily basis as acutely as those in dense urban and suburban communities. 4/

Second, Medicaid, in conservative/rural communities, is viewed as a handout, whereas its close cousin Medicare is viewed as an inalienable right (everyone hates welfare unless it's their welfare). Both serve as a lifeline, one is viewed as something to be ashamed of. 5/

Third, folks in these communities have seen, over the last several decades, the purchasing power of the dollars they bring home steadily decrease, while at the same time, they see medical bills continue to increase and take up ever larger portions of their budgets. 6/

They chafe at the idea that they continue to struggle and someone else (struggling more) would get medical care for free through Medicaid. 7/

Fourth, there is a very real bootstrap mentality in these communities. "If you can, you should help yourself". People that have never struggled to the point that they need Medicaid to cover medical expenses struggle to understand the mentality of accepting a handout. 8/

Fifth, Medicaid is seen as something that "people in other communities use". In the collective imagination, this often conjures images of minorities who are poor, who do not look like the vast majority of rural communities. It makes it hard to relate to this mental image. 9/

This is of course, not true. Vast swaths of rural, white, people who are poor will benefit from Medicaid expansion. But that's not the beneficiary most people conjure in their mind. We've been conditioned not to. 10/

Finally, Medicaid expansion is seen as an extension of Obamacare (which it is). That has (on balance) negative connotations in many communities, even as public opinion continues to move in favor of the policies and rights it enshrines into law. 11/

Hospitals, lawmakers, and government all have a lot of work that still needs to be done to de-stigmatize Medicaid in some of these communities. Getting the funding in place is a battle, not the war.
The roll-out & building trust are just as equally, if not more, important. 12/12