JEFFERSON CITY, Mo. -- More than 1 million people are expected to participate in what amounts to the largest public opinion poll on the nation's new health care law.
Missouri on Tuesday will become the first state to the test the popularity of President Barack Obama's top policy accomplishment with a statewide ballot proposal attempting to reject its core mandate that most Americans have health insurance.
The legal effect of Missouri's measure is questionable, because federal laws generally supersede those in states. But its expected passage could send a political message to Democrats seeking to hang on to their congressional majority in this year's midterm elections.
Locally, only one hospital had an official statement on the proposition. Saint Francis Medical Center president and chief executive officer Steven C. Bjelich said if Proposition C is approved, Missouri hospitals will be at a significant disadvantage.
"Eliminating the federal health insurance mandate will significantly reduce the number of Missourians otherwise expected to obtain coverage under the Affordable Care Act," he said in a statement. "This will have negative consequences for Missouri hospitals, because they will experience Medicare and disproportionate-share hospital payment reductions designed to fund higher levels of coverage."
Southeast Missouri Hospital and the Missouri Foundation for Health said their policy is not to issue comments or promote sides on ballot issues. Cross Trails Medical Center did not return calls seeking comment.
From Florida to Washington and numerous states in between, Republican candidates for the U.S. Senate and House -- and even for local offices that have little to do with the federal law -- are calling for the repeal of what they dub as "Obamacare."
It's reached a point that "the debate over the health care bill is not really so much over the specifics of the health care bill," said Florida-based Democratic consultant Marc Farinella. "It's become a surrogate for a debate over the direction of the country, or the direction of the Obama administration."
A year after raucous town-hall forums and months after Obama signed it into law, the health care overhaul remains divisive and national polls differ on its popularity. A Kaiser Family Foundation poll found approval grew to 50 percent while disapproval shrunk to 35 percent in July. A Pew Research Center poll showed the opposite, with approval falling to 35 percent and disapproval rising to 47 percent.
In Missouri, 61 percent of respondents to a Mason-Dixon poll conducted this month for the St. Louis Post-Dispatch and TV station KMOV said they opposed the federal health care law. Opinion generally split along party lines, but among the key category of independents, 65 percent said they disapproved.
If passed by voters, the proposed Missouri law would prohibit governments from requiring people to have health insurance or from penalizing them for paying health bills entirely with their own money. That would clash with a key provision of the new federal law requiring most Americans to have health insurance or face fines starting in 2014.
Similar measures are to appear as state constitutional amendments on the November ballot in Arizona, Florida and Oklahoma. And similar laws already have been enacted -- without statewide votes -- in Arizona, Georgia, Idaho, Louisiana and Virginia.
Supporters hope the state measures will provide ammunition for court challenges over the constitutionality of the federal health insurance mandate.
But the federal health care law already has become a key part of Missouri's primary elections.
The ballot measure is backed both by U.S. Rep. Roy Blunt, the Republican front-runner for U.S. Senate, and by his Republican rival, state Sen. Chuck Purgason, a favorite of many tea party activists. Blunt's TV ads claim the leading Democratic Senate candidate, Secretary of State Robin Carnahan, would "rubber stamp" Obama's agenda of "more government control of health care."
Carnahan, while expressing support for the health care law, generally has ignored it in her stump speeches, instead focusing her rhetoric against bailouts of banks and big corporations.
Various Republican candidates in Missouri have contributed money to a specially created campaign committee for the ballot measure, which has been running radio ads and printing yard signs.
Opponents, who failed to remove the measure from the Missouri ballot with a lawsuit, had no organized campaign until several college-age students recently launched a Facebook-driven effort to hold opposition rallies in Kansas City and St. Louis.
The Missouri Hospital Association now also is mailing letters to hundreds of thousands of homes suggesting hospitals could incur costs of about $50 million annually in treating the uninsured if the state proposal is passed and upheld in court.
Even in states lacking similar ballot measures, the federal health care law has emerged as a key campaign theme.
In Arkansas, opposition to the "job-killer" health-care law is a central part of Republican U.S. Rep. John Boozman's challenge to Democratic Sen. Blanche Lincoln. Wisconsin Republican Ron Johnson, running against three-term Democratic Sen. Russ Feingold, has called the health overhaul "the greatest assault on our freedom in my lifetime."
The health care law also has played a role in Michigan's governor's race, where all five Republican candidates have signed pledges not to force residents to get insurance as the federal law requires.
But the effect of the health care law on the general election is less clear. And opinions could change as parts of the law soon take effect, including the issuance of checks to seniors to fill the so-called prescription drug doughnut hole and the ability for children up to age 26 to stay on their parents' insurance plans.
"It's going to be a problem for the Democrats who are in those maybe 50 or 60 Democratic-held [congressional] districts that are in play -- districts that have tended to vote for Republicans in the past," said Alan Abramowitz, a political science professor at Emory University, who has observed similar health care campaign themes in his home state of Georgia.
But otherwise, "I think it's going to be based more on people's overall feelings on Obama and the economy and less about health care."