After a delay due to a lack of funding from the Missouri General Assembly and resulting litigation, the initiative was implemented in October 2021, albeit slowly.

[4] In the late 2010s, the Fairness Project supported successful ballot initiatives to expand Medicaid under the ACA in states where Republican leaders were unwilling to.

[6] Conservative organizations United for Missouri and Americans for Prosperity's Missouri branch filed lawsuits to prevent the expansion from appearing on the ballot, arguing the initiative violated a constitutional requirement for ballot initiatives to cite a funding source when appropriating funds.

Local governments expect costs to decrease by an unknown amount.The deadline for the state to implement the specified Medicaid expansion was to be July 1, 2021.

[5] The initiative was opposed by Republican politicians such as Governor Parson, who said that the state could not afford its share of the Medicaid expansion's cost.

Parson replied that he scheduled it in August to allow the state to understand, as soon as possible, whether it would need to account for extra spending in its budget assuming the initiative passes.

[5] The amendment has been cited as an example of the popularity of expanding Medicaid, occurring weeks following the success of a similar ballot initiative in Oklahoma.

Following the budget's passage, Governor Parson announced the state would be unable to expand its Medicaid program before the July 1 deadline.

[14] Implementation was slow, with only 7% of newly eligible Missourians enrolling in the expansion's first month, compared to about 50% in Idaho and Montana.

[22] The following year, Republican lawmakers proposed requiring that 60% of voters approve of any future state constitutional amendment to make it more difficult for them to pass.