Mariamee Rodriguez writes on a sign during a protest in support of Florida lawmakers expanding eligibility for Medicaid as called for under the Affordable Care Act, Thursday, Jan. 8, 2015, in Miami. | AP Photo/Lynne Sladky Health Care Groups quietly mount Medicaid expansion ballot campaign in Florida

Obamacare supporters are mounting a campaign to get Medicaid expansion on the Florida ballot in 2020, potentially elevating the Obamacare program as a key election issue in the presidential swing state.

A mix of national and local health care groups, energized by the approval of Medicaid expansion ballot initiatives in three conservative states in November, have been collecting signatures for weeks to support a voter referendum that could cover an additional 700,000 low-income Florida adults. For now, however, the groups aren't saying much publicly about the effort.


Adding Florida to the ranks of Medicaid expansion states is seen as a huge prize for Obamacare supporters. Only Texas, which doesn’t allow citizen-initiated ballot measures, has a larger population that would gain coverage by joining the optional coverage program.

Still, the effort faces obstacles in Florida that other successful Medicaid expansion ballot measures didn’t. A campaign in the populous state could easily cost tens of millions of dollars, dwarfing what the law’s supporters spent to help pass similar initiatives in Idaho, Maine, Nebraska and Utah. And while those states only needed a simple majority for approval, Florida ballot measures must get at least 60 percent support.

“What our approach has been on these ballot initiatives is you don’t actually take it to the ballot unless you feel you’re going to win,” said Patrick Willard of consumer advocacy group Families USA, one of the groups involved in the effort. “That doesn’t mean that you don’t start the process — especially in a state as complicated as Florida — and try to meet the signature goals on the front end just to get the things off the ground.”

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Obamacare supporters were cleared by the Florida Division of Elections to begin collecting signatures in December. Since then, they have been holding events around the state, trying to net 100,000 signatures by the end of this month to improve the odds of getting on the ballot.

“Medicaid expansion is very long overdue in Florida,” said Florida Voices for Health Program Director Louisa McQueeney, who said the ballot effort is “just in the preliminary stages” and declined to elaborate further.

Other groups involved include SEIU, Planned Parenthood, Organize Florida and Indivisible, among others, according to people involved in the campaign. Many of the groups did not provide more details or did not respond to inquiries.

Medicaid expansion appears to be popular among Florida voters, as it is in some other conservative states that haven't joined the program. About 60 percent of voters support expansion, according to an October poll from the Kaiser Family Foundation. However, the issue remains highly controversial among Republican leaders in Florida, and it could antagonize conservatives in a state that will be crucial to President Donald Trump's reelection effort.

The Republican-led Florida House of Representatives has long opposed Medicaid expansion. Former Republican Gov. Rick Scott briefly endorsed Medicaid expansion in 2013 before opposing it. New Gov. Ron DeSantis, also a Republican, campaigned on opposing Medicaid expansion, and he is likely to embrace the Trump administration’s encouragement to curtail the traditional Medicaid program.

Although ballot measures in other states have been successful, the strategy hasn’t been without its setbacks. In Maine, where voters approved the first expansion ballot measure in 2017, former Republican Gov. Paul LePage refused for over a year to implement the program. The coverage expansion only took effect last month after his Democratic successor, Janet Mills, was sworn in.

GOP legislators in Utah are also moving to pare back the coverage expansion voters approved in November, citing new estimates that the program will cost the state more than expected.

Medicaid ballot measures in Utah and other states were bankrolled by the Fairness Project, a Washington, D.C.-based group founded by SEIU-United Healthcare Workers West to boost progressive causes around the country. The group spent roughly $6 million on expansion campaigns in three states last year, according to a spokesperson.

The Fairness Project hasn’t decided whether it will support a ballot effort in Florida, but it continues to evaluate potential 2020 targets and talk with local advocates. Other than Florida, the group has said it’s eyeing possible ballot measures in Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.

Representatives from the Fairness Project are also participating in a closed-door 2020 ballot initiative briefing in Washington, D.C. on Wednesday with America’s Health Insurance Plans, the health insurance industry’s main lobbying organization.

“We’ll take a look at successful expansion efforts, examine effective campaign strategies, and explore future 2020 activities,” according to the AHIP invitation obtained by POLITICO. The trade group did not respond to questions about whether it is formally working with the advocacy group or if it is funding measures for the 2020 cycle.

"AHIP’s members include many of the nation’s leading Medicaid managed care organizations, and this is an internal briefing to which they are invited," said spokesperson Kristine Grow.

To get Medicaid expansion on the Florida ballot, supporters must have 800,000 valid signatures from 14 of the state's 27 congressional districts certified by February 2020.

John Morgan, an Orlando lawyer who spent millions on a 2016 ballot campaign to legalize medical marijuana in Florida and is supporting a 2020 ballot measure to increase the minimum wage, said a successful Medicaid expansion campaign wouldn’t come cheap. Morgan estimated that an ad campaign supporting the minimum wage increase will cost at least $10 million, on top of the millions needed just to get on the ballot.

“I think you might need more on Medicaid expansion,” said Morgan, who’s not involved in the Medicaid effort.

One Florida GOP operative believes that Republican lawmakers could mount their own ballot effort to counter the Medicaid expansion measure.

“I’m sure there’ll be a lot of political push for them to do that,” said the operative, who requested anonymity to discuss political strategy.