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The Ballot Revolt to Bring Medicaid Expansion to Trump Country

Next month, voters in Utah and Nebraska will decide measures to expand Medicaid and polling suggests they have a good chance of passing. But the Idaho ballot initiative may be the most audacious of them all.

The activists leading an Idaho ballot initiative on Medicaid expansion have taken to the road in the Medicaid Mobile, now a familiar sight in the state,Paul Demko/POLITICO

SANDPOINT, Idaho — One month before Election Day, about 30 volunteers packed into a home in this northern Idaho town in the heart of Trump country, preparing to knock on doors to build support for a ballot measure to adopt Obamacare’s Medicaid expansion.

Luke Mayville, an Idaho native who’s helping to lead the effort to bring more health care to lower income people in his home state, gave a blunt assessment to the activists: “It’s a tragedy if we lose,” he said. “If we win, we make history.”

Next month, voters in two other conservative states, Utah and Nebraska, will also decide on Medicaid expansion, and polling suggests they have a good chance of passing. Montana will also vote on keeping its program. Maine voters last year were the first to approve Medicaid expansion through the ballot, although Republican Gov. Paul LePage has done everything possible to block expansion in his final year in office. A few other holdout states — most notably Georgia, Florida and Wisconsin — would also become much more likely to embrace Medicaid expansion if Democrats prevail in gubernatorial contests next month.

If successful, this year’s ballot measures would mark the most significant growth of Medicaid expansion since the early phase of the Affordable Care Act — and a resounding rebuke to GOP lawmakers in states that have rejected a program that’s financed mostly with federal dollars. It would also come as the Trump administration tries to shrink Medicaid and Republican lawmakers in Washington hope to take another crack at Obamacare repeal, perhaps as early as the lame-duck session of Congress after the midterm elections.

Idaho is arguably some of the least fertile ground in the country to cultivate a grassroots campaign to massively expand government-backed health care. Republicans dominate the state’s politics, with a more than 4-to-1 registration advantage over Democrats and overwhelming majorities in both legislative chambers. Bonner County, which includes Sandpoint, backed President Donald Trump by a 2-to-1 margin in the 2016 election.

But the state also has a fierce independent streak that’s been apparent in its approach to Obamacare. It’s the only Republican-led state to fully run its own health insurance marketplace, which has been far more competitive than others in similarly sparsely populated states. Yet even while creating that unexpected success story, state officials this year pushed a proposal to create skinnier health plans exempt from Obamacare rules, and lacking protections for pre-existing conditions. It was too radical even for the Trump administration.

Now Mayville is attempting to turn that independence into a grassroots revolt: In the campaign’s final 30 days, he plans to hit all 44 Idaho counties, often in the ramshackle green “Medicaid Mobile” that has become a kind of mascot for the campaign.

Medicaid expansion has proven a bridge too far for the state’s conservative lawmakers, who’ve rebuffed numerous proposals to cover low-income residents. That drove Medicaid expansion supporters to take matters into their own hands, organizing an 18-month statewide campaign to get it on the ballot.

“[People] got very frustrated with the fact that the legislature was not able to do something, and they really took it upon themselves to come out and start an initiative process, which is very rare in this state,” said state Rep. Christy Perry, a Republican, who is co-chairing the campaign to pass the ballot referendum and championed the most recent failed legislative effort to expand coverage. “And for me, that gives me hope.”

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Republican Lt. Gov. Brad Little, the easy favorite to win November’s gubernatorial contest, said he hasn’t ruled out voting for the Medicaid referendum, which would cover more than 60,000 Idahoans. He’s also not threatening to follow the path of LePage and block implementation if it passes.

“I’m fully committed to honoring the will of the people if that happens,” Little said.

The Republican-dominated Legislature, which would have to fund the program, could be less accommodating. Staunch Obamacare foes in the state who haven’t given up on the law’s repeal will likely pressure lawmakers to ignore voters if the ballot measure is successful.

“I think we’re at a fork in the road,” said Fred Birnbaum, vice president of the Idaho Freedom Foundation, the main group fighting the referendum. “If Idaho and Utah and Montana [and] Nebraska and other states expand Medicaid, it will be harder for Congress to reverse that. I think that is going to put us on the path to a … single-payer system.”

Opponents of the measure argue Medicaid expansion has proven more expensive than projected in other states that have moved forward and could jeopardize funding for other crucial services such as education and transportation. They also believe it could prove a disincentive to work, since beneficiaries could be putting their health care coverage at risk if they make too much money.

But the campaign has formidable support from pretty much the entire Idaho medical establishment, which would benefit greatly from such an expansion because more of their patients would be able to pay their bills. The Idaho Hospital Association, the biggest financial supporter, has contributed $150,000. The Idaho Medical Association, the state’s largest physician organization, has chipped in nearly $50,000.

A poll conducted this summer showed a whopping 70 percent of Idahoans support closing the “coverage gap” by expanding Medicaid. The coverage gap refers to individuals in Idaho and other non-expansion states that make too much to qualify for Medicaid, but too little to access Obamacare’s subsidies for private insurance. They’re essentially left with no options for obtaining coverage. 

A huge unmet need for care

Jessica and Patrick Rachels, who have twice gone out knocking on doors to support the referendum, are among the Idahoans who could gain coverage. Jessica Rachels is a mother of four and full-time caregiver for her 12-year-old daughter born with severe mental and physical disabilities. She also takes care of her elderly father, who lives with them and struggles with diabetes and Parkinson’s disease. Patrick is a self-employed computer technician. Their household income is about $25,000.

“I make enough to pay the bills and get things fixed and barely get my head above water,” Patrick Rachels said, during a recent interview at their home just outside of Sandpoint.

Their children are all covered through Medicaid, but Jessica and Patrick have been without coverage most of their adult lives. The income cutoff for Medicaid eligibility for parents with four kids in Idaho is about $7,000, far stingier than in many other states. Under expansion that threshold would rise to about $33,000.

The Rachels pay out of pocket for care at a community clinic but go there only when absolutely necessary. Jessica was recently diagnosed with bipolar disorder, and now takes medications that cost about $60 per month.

“Having that label of mental illness is sometimes hard to swallow,” she said. “But it’s nice to have an answer after probably suffering with it for about 16 years.”

The couple ignores other health problems. Jessica has chronic foot and back pain related to the physical demands of taking care of her daughter, and she has put off foot surgery because it would cost about $20,000. Patrick was diagnosed with a hormonal imbalance that makes sleeping difficult, but he’s put off treatment.

Patrick describes himself as a “constitutional conservative Republican” who nonetheless supports expanded coverage.

“It’s not a free-for-all,” Patrick said of Medicaid expansion. “This is money that we’re already sending to the feds.”

This argument has been central to the campaign’s approach to wooing conservative voters: People in Idaho pay federal taxes, some of which ends up going to other states to help pay their Medicaid bills.

Health care providers also say they would be massive beneficiaries if tens of thousands of Idahoans suddenly gained coverage. Terry Reilly Health Services cares for about 40,000 patients at more than a dozen clinics in southwest Idaho, and the community health center estimates about half of those patients aren’t covered. That would likely change dramatically if Medicaid is expanded.

CEO Heidi Hart said the provider is now only reaching about 20 percent of its target population, which is individuals earning up to twice the poverty level — about $24,000 for an individual.

“We’re not sure where they’re getting care or if they’re getting care,” Hart said. “There’s a huge unmet need with that population.”

Among the areas where she wants to expand is Caldwell, a poor, rapidly growing town about 30 miles west of Boise. The clinic purchased land last year to establish a second clinic in the area, but so far hasn’t been able to afford to build a facility.

Robyn Page, 56, is among Terry Reilly’s patients who would likely be eligible for Medicaid under expansion. A substitute teacher and caregiver for her disabled adult son, Page currently takes prescription drugs to control diabetes, high blood pressure and other ailments. But she sometimes lets prescriptions lapse when she doesn’t have enough money for refills.

“One time I went a couple weeks without my heart medicine, and by the end of the time I was relying on my nitroglycerin quite a bit [to control chest pain], where before I didn’t have to,” said Page, a resident of the rural town of Homedale, about an hour west of Boise. “And so I learned that that’s one I definitely can’t go without.”

How the campaign got started

The story of Idaho’s Medicaid ballot measure really began early in 2017, with a funding referendum for the Lake Pend Oreille School District.

With one-third of the school district’s budget on the line, 33-year-old Mayville, childhood friend Garrett Strizich — both products of Lake Pend Oreille schools — and Garrett’s wife Emily decided to go all in organizing support for the initiative. It passed with nearly two-thirds support, succeeding beyond their wildest dreams.

That got the trio thinking about acting statewide, which eventually led them to focus on Medicaid expansion. They believed it would resonate with voters, given the uproar over efforts to repeal Obamacare happening in Washington at the time. Maine’s campaign to pass expansion through a referendum, which was also underway, offered a blueprint for a path forward.

The trio stress that the campaign is nonpartisan and they aren’t actively involved with either political party. According to state records, Mayville and Emily Strizich aren’t registered with a political party, and Garrett Strizich is registered as a Democrat.

Mayville seems like an unlikely candidate to spearhead a campaign to expand Medicaid in Idaho. He’s got a doctorate from Yale in political science and is currently teaching at Columbia University, 2,500 miles away in New York City. But his mother still lives in Sandpoint, and he just bought a house in Boise.

Their efforts were initially met with skepticism from influential individuals they sounded out across the state. The biggest fear they heard was that if the campaign failed, it would re-enforce the perception that Idahoans don’t support expansion and make it even more difficult to do something to help those in the coverage gap. But an initial 20-city tour in the newly painted Medicaid Mobile emblazoned with “Medicaid for Idaho” — which the Strizichs had purchased off eBay for $1,500 years earlier — in the summer of 2017 convinced them that the skepticism was misplaced.

The campaign collected 75,000 signatures from across the state, easily surpassing the 56,000 required for a ballot measure. They got help from the Fairness Project, a national organization based in Washington, D.C., that’s trying to build support for Medicaid expansion in holdout states, which spent about $500,000 collecting signatures. Mayville said about three-quarters of the signatures were collected by more than 1,000 volunteers, with the rest by the Fairness Project’s canvassers. 

‘I just think health care should be for everybody’

With weeks before Election Day, Mayville headed in the Medicaid Mobile to Priest River, about 20 miles southwest of Sandpoint, to knock on doors.

Northern Idaho isn’t politically friendly territory for progressives: GOP state Rep. Heather Scott, a staunch conservative who represents the area, won reelection with 86 percent support in 2016. But Mayville is finding people are receptive to his pitch.

The first house where he gets a response is a young family of five who recently moved to Priest River so the husband can work construction jobs. Abi Berman tells Mayville that the entire family is currently uninsured, although the kids are likely eligible for Medicaid.

“This is really important because we need every single vote and your health care is on the line,” Mayville tells her.

The next visit turns up 63-year-old Arthur Thayer, who says he delayed surgery on his hip for years because he was uninsured and couldn’t afford the $40,000 cost. The ailment eventually landed him on disability, allowing him to enroll in Medicare early.

“I just think health care should be for everybody,” Thayer says.

At the last house of the day, Mayville meets 99-year-old Dewie Rogers, who takes several minutes to reach the door using a walker. She expresses enthusiasm for the Medicaid referendum, but isn’t sure she can make it out to vote.

“I’ll try,” Rogers says. “I’m having a hard time doing too much anymore because I’m too old.”

Mayville was ready for this. He helps Rogers fill out a request for an absentee ballot.

Later that afternoon, Mayville and Emily Strizich — and her infant daughter, Simone — will head to Coeur d’Alene in the Medicaid Mobile for the grand opening of a skate park. The next afternoon they’ll pilot the green camper an hour east to Wallace (pop. 784), the self-proclaimed “center of the universe,” for a meeting with four local supporters. And then on to Idaho’s 41 other counties.

Over and over, Mayville will invoke a simple mantra that he believes will convince skeptical Idahoans to back one of the most significant pieces of Obamacare: “Sixty-two thousand Idahoans need health care; we’re already paying for it.”

This story was produced with the support of the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School of Journalism's Center for Health Journalism.

Paul Demko is a health care reporter for POLITICO Pro. He's primarily responsible for covering the insurance industry. Prior to joining POLITICO, he was the Washington bureau chief at Modern Healthcare. Demko also spent a decade reporting in Minnesota, including stints with Politics in Minnesota and City Pages. He started his career at The Chronicle of Philanthropy.

Demko is a graduate of New York University. He is an ardent soccer fan and has traveled to Germany and Mexico to watch matches. Follow @pauldemko