UPDATE, November 7, 3:05 p.m.: Voters in Utah, Nebraska, and Idaho on Tuesday approved ballot measures to expand access to Medicaid. Medicaid expansion in these states will save hundreds of lives every year, according to a recent study.

At least 15 million people have gained health insurance under the Affordable Care Act’s Medicaid expansion. Today, fewer people struggle to pay medical bills, or avoid going to the doctor over fears of high health-care costs.

But 19 mostly Republican-led states rejected federal money for Medicaid, according to the Kaiser Family Foundation, leaving uninsured nearly 2.5 million people with low incomes who fall into a coverage gap. Half are Latino or Black.

Some of these holdout states are now putting the Medicaid expansion question to voters. Here are four states to watch next year.

Utah

Pat Fleming figures he has knocked on a couple hundred doors in his Salt Lake City neighborhood asking folks to sign a petition to expand Medicaid. His appeal is simple.

“I say these people can get coverage and they won’t have to go to the emergency department and drive up costs for everybody,” said Fleming, 66, a retired county behavioral health director.

A signature-gathering campaign called Utah Decides Healthcare aims to put the question of Medicaid expansion to Utah voters in November 2018. The initiative would extend health care to people and families making below 138 percent of the federal poverty line, which is less than $16,642 for an individual. The federal government would pick up most of the tab to expand the program, and Utah residents would cover the balance with a slight sales tax increase, according to the campaign.

The initiative needs 113,143 signatures by the middle of April to qualify for the ballot. Fleming estimates he has gathered close to 100. He said many Utahans are conservative, but compassionate.

“When I get somebody to answer the door, most of them are in favor of Medicaid expansion,” Fleming said.

Maine

In November, Maine became the first state to expand Medicaid eligibility through a ballot initiative. A joint committee of state lawmakers met Wednesday to discuss key details, including when the program would start, how many individuals might enroll, and estimated costs and savings.

Luke Lazure, fiscal analyst with the state Office of Fiscal and Program Review, said the state could expect a “big chuck of savings” as people in the state mental health and substance abuse program switch to Medicaid, which is mostly funded by the federal government.

Lawmakers must still figure out how to pay for the state’s share of the costs. Projections suggest the first full year in 2019 could run the state $64 million. Lazure, however, said that number doesn’t account for anticipated cost savings.

The program start date is July 2, but Maine must hit a few deadlines before then. A state plan amendment is due to the Centers for Medicare & Medicaid Services (CMS), which administers Medicaid, by April 3. CMS then has 90 days to respond.

Meanwhile, Republican Gov. Paul LePage, who vetoed Medicaid expansion legislation five times and vowed to thwart the successful ballot measure, issued a strongly worded letter on Monday to lawmakers refusing to fund health care for low-income Mainers with new taxes or “budget gimmicks.”

Pro-expansion advocates said LePage continues to muddy the push to make Medicaid available to more Maine families with demands about how state officials can or should execute the will of the voters.

“There’s no reason to believe that he won’t continue to do every thing he can to stall implementation,” David Farmer, spokesperson for Mainers for Health Care, told Rewire. “[LePage has] been very upfront about his goals all along. He opposes Medicaid expansion, has always opposed it, and will do whatever he can to hinder implementation.”

Jack Comart, litigation director for Maine Equal Justice Partners, told Rewire that the LePage administration’s refusal or failure to implement Medicaid expansion “will result in litigation.”

“The fact that the governor does not like the results does not put him above the law. He is charged with faithfully executing the laws,” Comart said. “[LePage’s] fight with the legislature over funding levels for expansion is legally irrelevant. Once the state is in the federal Medicaid program, Maine must timely process applications and provide services regardless of these funding fights.” 

Idaho

Garrett Strizich heard personal stories about the health-care crisis while crisscrossing the state this summer in a 1977 green Dodge camper called the Medicaid Mobile.

Strizich is co-founder of Reclaim Idaho, a group leading a ballot initiative effort to expand Medicaid in Idaho.

“Everybody we talked to knew someone who is struggling with health care, or is struggling themselves,” Strizich, a a 32-year-old medical school student, told Rewire.

Reclaim Idaho aims to gather about 56,000 signatures by the end of April to put the question of Medicaid expansion to state voters in November 2018. An estimated 78,000 low-income Idahoans could gain coverage.

Strizich said the group is hosting a big kickoff event Saturday in Sandpoint, and is forming teams around the state to collect signatures. Some 70 percent of Idahoans favored Medicaid expansion, according to a 2017 survey by Boise State University, but the Republican-held legislature has rejected recent proposals.

Strizich said it’s time now to act.

“We’re already paying taxes to pay for Medicaid expansion in 32 other states, but because our local legislature has decided not to pass expansion, we’re not seeing the benefits,” he said.

Florida

Two Florida Democrats filed twin resolutions last week to amend the state constitution to expand Medicaid. The measures would extend health-care coverage to individuals younger than 65 living at or below 138 percent of the poverty line—$16,642 per year. Roughly 877,000 Floridians are uninsured.

Nearly 70 percent of Florida voters support Medicaid expansion, according to a recent University of Maryland study. But the legislation faces an uphill battle in the Republican-led legislature.

State Sen. Annette Taddeo (D-Miami-Dade), a bill sponsor, vowed in a news conference last week to take the question directly to voters if Republicans like Gov. Rick Scott stand in the way.

“We know we’re in a campaign year, we’re ready for this fight,” said Taddeo, who won a special election this year, flipping her seat from Republican to Democratic control. “We’re ready for the legislature to do the right thing for Floridians, and if they don’t, we will take it to the ballot.”

Senior News Editor Dennis Carter contributed to this report.