FREDERICKSBURG, Virginia — Vellon Harris will lose her health insurance on November 7, the day Virginians will decide whether they’ll give Democrats the chance to expand health insurance in their state.

Harris is a home health care worker whose employer does not offer insurance, and she’s also currently a canvasser hired temporarily by the Service Employees International Union for this November’s Virginia gubernatorial election, which is how she’s getting health insurance. But as soon as Election Day comes and goes, Harris will return to her job assisting elderly health care patients — and lose her coverage.

If Virginia had expanded Medicaid, Harris and about 400,000 other Virginians would have health insurance. But it didn’t, and Harris, who makes about $25,000 per year — or too much to qualify for Medicaid in the state — is scrambling to get all the medical care she can now for her high blood pressure, long-overdue trips to the dentist, and pain in her knees.

“I’m getting all the treatment I can right now,” Harris, 53, said at a Starbucks in Fredericksburg. “The dentist wanted to give me a temporary filling and to come back in two months, but I can’t do that; I won’t have dental then.”

Most of the national attention on the November 7 election is about the battle between Republican Ed Gillespie and Lt. Gov. Ralph Northam, a Democrat, for the governor’s mansion.

But for voters in the state, there are some bigger policy stakes on the ballot: If enough Democrats get elected to the legislature, they can expand Medicaid under the Affordable Care Act. Whether Democrats can regain the statehouse, redraw Virginia’s congressional districts, and fulfill one of Obamacare’s promises will depend on dozens of below-the-radar statehouse races. And despite a surge in interest from previous years, it’s still not clear Democrats on the ground have the resources to win.

“We're being outspent in a lot of races, and that's always a concern,” said Trent Armitage, executive director of Virginia’s House Democratic Caucus. “The way you win these races is by really making sure you pay a full budget in all categories — meaning field, digital, mail, and TV. And if you can't fill all these buckets, you're not giving yourself the best chance of winning these races. You need a lot more money than we have to do that.”

The critical health care stakes of the race

Virginia is looking like an increasingly blue state. Barack Obama won it twice, Hillary Clinton cruised to a 5-point victory, and it has two Democratic senators.

And yet its health care system much more closely resembles that of Republican-controlled states in the Deep South.

That’s been disappointing for many in the state, particularly those who hover just above the cutoff for Medicaid. Dorren Brown, the director of a free clinic in Virginia’s Orange County, in one of the poorer sections of the state, remembers crying with joy when she learned that Obamacare would be signed into law.

“We were really hoping our patients were going to qualify and get insurance or Medicaid,” said Brown, 63. “We thought it would lighten our load and get our patients the health care they need.”

More than seven years later, Brown and her team are still waiting. The free clinic is only staffed with seven full-time workers and relies heavily on volunteers. It has a patient list of 3,300 people, about 900 of whom it sees in an average year. Brown said the clinic needs the Virginia Medicaid expansion to remain solvent and free of the constant emergency fundraisers it routinely holds.

“We were excited to get people signed up [for Obamacare] in 2011. But we had maybe six people who qualified,” Brown said. Of those six, none of them are still on Obamacare’s exchanges. “They all came back to us within a year. I hate to say it: I loved Obama, but we really didn't see any difference.”

This is similar to the experience of Harris, the SEIU canvasser and health care worker who will lose her insurance in a few weeks. She signed up for a bronze plan on the ACA but couldn't meet its copayments, and promptly dropped out. Every year, she goes to the state capitol in Richmond and tells her representatives how badly she and her co-workers need health care — pleas that fall on deaf ears.

“People just don't understand,” she said. “It's hard, and we need help.”

Why down-ballot races in Virginia are really important

But despite the high stakes, some Virginia Democrats close to the campaign to retake the statehouse worry that a lack of cash will hamstring the party’s ability to make substantial gains.

Gov. Terry McAuliffe, a former Clinton aide and the current incumbent, is not the only Democrat to recently be elected governor of Virginia (McAuliffe tried and failed to expand Medicaid in the state without the legislature’s approval in 2014) — Democrats have controlled the state’s governor’s mansion for 11 of the past 15 years. And that, in turn, has bred a degree of down-ballot complacency among liberal voters in a state that voted for Obama twice and Clinton once — one that mirrors a problem nationally for Democrats, who lost statehouse seats in historic numbers during the Obama era.

“A lot of people — as they do with the president — fall into the trap of, ‘Once I vote for governor, my job is done,’” said Jennifer McClellan, a Democratic state senator in Virginia. “But at the end of the day you still need the legislature to get anything done.”

There’s some reason for liberals to be optimistic that the statehouse can be reclaimed — if not this year, then perhaps down the road. Republicans currently control 66 of 100 seats in the Virginia House, meaning that Democrats can retake the chamber with 17 victories in November. And by remarkable coincidence, Hillary Clinton won precisely 17 red Virginia statehouse districts in 2016, giving liberals reason to believe they are winnable. (The Democratic path to reclaiming the state Senate is easier, given that Republicans only have a two-seat advantage there.)

McAuliffe predicts Democrats will gain six to eight seats in the House this year, which would put them in a much stronger starting position ahead of 2019.

The stakes of the race could hardly be higher, and they extend well beyond the fate of Medicaid expansion. In addition to helping secure health insurance for 400,00 people, Northam has vowed to increase the minimum wage for state residents to $15, to dramatically reduce college costs for students, and to create pre-K programs. He’ll almost certainly be unable to do so with a Republican legislature.

Perhaps just as importantly, Republicans in the state have a history of extraordinary gerrymanders that redraw the state’s congressional districts for their partisan gain. Democrats are fighting right now to control that process after the next census — a fight that may in turn shape future battles for the US House of Representatives.

“What Democrats in Virginia need to understand is that 2021 is on the ballot right now. The winners in 2017 will be in charge of redistricting after the 2020 census, and the technology and the data Republicans used to draw deeply flawed lines has not gotten worse,” said David Daley, author of Ratfucked, a book about Republican gerrymandering.

“We need people to panic”: House Democratic candidates are doing better but are still being badly outspent

Several gettable seats for Democrats are in or near the Washington, DC, media market — which makes getting on television exorbitantly expensive for the state legislature campaigns often run on shoestring budgets. The campaigns view getting on TV as essential for exposure in low-budget races outside the national spotlight.

Making the money slog harder for Democrats is the fact that statehouse Republicans have formidable fundraising prowess, particularly since so many of them are incumbents who have been building up their war chests for years. An analysis the Daily Kos’s Carolyn Fiddler sent to Vox found that at least 14 Democratic challengers — including in crucial races like House District 51, which encompasses part of Prince William County — out-raised their Republican opponents in the short term but still have less money to spend in the last few days of the race because often Republican incumbents have been raising money for reelection since they first arrived in office years ago.

“Of course there’s not enough investment,” the campaign manager for one House Democratic candidate in Virginia said. “We need people to panic; we need people to pitch in — or Republicans will win.”

Particularly frustrating for some candidates is that national donors spent millions of dollars on Democrat Jon Ossoff’s failed bid to capture a seat in a deeply conservative House district outside Atlanta, while Virginia statehouse candidates are struggling to raise $1 million to compete in districts Clinton won. Armitage, of the Virginia House Democratic Caucus, listed several races where he thoughts Democrats had a chance but were being outspent — Districts 12, 31, 32, and 93. (You can find districts by location here.)

In mid-October, the Democratic National Committee made a substantial investment in several key House delegate races, Armitage said. And several candidates interviewed by Vox said their fundraising is ahead of schedule, and praised national Democrats, including DNC Chair Tom Perez, for investing resources in the state.

“To be honest with you, we haven’t had any money problems of our own,” said Chris Hurst, a former TV news anchor running as a Democrat for the Virginia statehouse in the 12th District. “There hasn’t been a lack of ability to do what we want to do because of fundraising. We’re getting an incredible amount of help from the Democratic Party.”

But the formidable GOP war chest is still proving difficult to overcome. An influx of small and largely new left-wing organizations with little money hasn’t appeared to make up the difference. “I don’t know how many people have said to me, ‘I want to help with social media,’ and I just say to them, ‘What the fuck does that mean?’” said Alex Vuskovic, the campaign manager of Donte Tanner, a Democrat hoping to take the House seat for Virginia’s 40th District.

Every campaign interviewed by Vox said they thought Democrats were beginning to focus more on these previously neglected statehouse races. But even Hurst, one of the candidates who was happy with the fundraising, argued that many liberals still seem uninterested in the campaigns.

And that could leave people like Harris and Brown to face life without the Medicaid expansion long past 2017.

“Voters just care, I think, by and large about what’s going on at the federal level ... and so their interest is going to be naturally drawn to those kinds of races,” Hurst said. “And I think there’s still too much of a top-down approach ... Which means congressional races will get more attention.”