Voters in Idaho, Nebraska and Utah may have the chance to do something their state lawmakers would not: expand Medicaid to thousands of residents.

After years of being told “no” by GOP-controlled state legislatures, health-care advocacy groups have spent much of 2018 leading campaigns to put the question on the ballot before voters in November.

Behind the scenes, those groups have been aided by The Fairness Project, a Washington-based organization that has become the primary funder of these ballot-initiative campaigns, spending close to $5 million in five states over the past year.

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“In so many places throughout the country, you have activists and also people who are impacted, folks who are desperate for health care, who just feel so disempowered because they go to their legislators and they hear ‘no’ over and over and over again,” said Jonathan Schleifer, executive director of The Fairness Project.

“It’s powerful that we have a vehicle for people to be able to take charge of their own lives and actually make policy themselves when it's so clear to them that their elected officials are failing,” he added.

State lawmakers have played a powerful role in determining whether to expand Medicaid to cover more low-income adults ever since the Supreme Court ruled in 2012 that the federal government can’t require states to do so, as instructed by the 2010 Affordable Care Act.

Thirty-three states and the District of Columbia have expanded Medicaid, while mostly red states have held out. Republicans argue Medicaid is already strapped for resources, and that expanding it to “able-bodied” adults only exacerbates the problem, while Democrats say expansion is a way to provide health coverage to the millions of low-income adults who are uninsured.

As Republicans have gained more power at the state level in recent years, issues mostly championed by Democrats have become increasingly difficult to advance through legislatures.

That’s where the Fairness project comes in. The group got its start in 2015 with a $5 million grant from United Healthcare Workers West in California, part of the Service Employees Union, which continues to be the group’s primary funder.

The group got its start supporting statewide ballot-initiative campaigns that looked to increase the minimum wage or expand paid family leave. They then added health care to their policy portfolio once it became clear that Donald Trump Donald John TrumpSteele Dossier sub-source was subject of FBI counterintelligence probe Pelosi slams Trump executive order on pre-existing conditions: It 'isn't worth the paper it's signed on' Trump 'no longer angry' at Romney because of Supreme Court stance MORE’s victory over Hillary Clinton Hillary Diane Rodham ClintonFox News poll: Biden ahead of Trump in Nevada, Pennsylvania and Ohio Trump, Biden court Black business owners in final election sprint The power of incumbency: How Trump is using the Oval Office to win reelection MORE in 2016 would pose a serious threat to the Affordable Care Act (ACA).

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“We didn’t have time to flip the House and the Senate in 2016 to play defense on the ACA,” Schleifer said. “The place we found the greatest opportunity to go on offense and create the clearest message that Americans don’t want less health care, they want more, is through expansion.”

Their first test case: Maine, where Gov. Paul LePage (R) had vetoed expansion five times.

The Fairness Project contributed $728,000 to Mainers for Health Care, the local group pushing for Medicaid expansion, between June 2017 and October 2017. Most of that funding went toward polling, campaign workers and ads.

When the expansion initiative won by 18 points in November 2017, the calls rolled in from advocates in red states who were frustrated by the unwillingness of their state leaders to expand Medicaid.

“We were quickly getting phone calls from other folks around the country in other states, where they’re like, ‘We saw what happened in Maine. We heard you had a part in it, and we’d love to partner with you,’” Schleifer said.

Now, voters in Idaho, Nebraska and Utah are expected to vote in November on whether to expand Medicaid to more low-income adults.

In Montana, where Medicaid expansion expires in 2019, voters will decide whether they want to make their expansion permanent.

Advocates in some states have been pushing their lawmakers to expand Medicaid for years — in some cases, since it became an option in 2014 under ObamaCare.

“They weren’t looking to use ballots until they saw Maine,” Schleifer said. “Maine was evidence for everyone that this was a strategy that could work.”

The Fairness Project has ramped up spending for 2018, particularly for the campaigns in Nebraska and Utah.

The group contributed more than $2.5 million between October 2017 and April 2018 to Utah Decides Healthcare, which has been working for the past five years to expand Medicaid.

“Our relationship with The Fairness Project was really about that initial investment to show Utah businesses and organizations and nonprofits that we were serious about this,” said RyLee Curtis, campaign manager for Utah Decides Healthcare.

A lot of that funding went to paid signature collectors, one of the most expensive aspects of a ballot-initiative campaign.

“We were able to collect a large amount of volunteer signatures, but the majority did come from the paid program because the requirements are so hard, and Utah is such a rural state,” Curtis said.

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The group needed 113,000 signatures, they got 147,280.

Proposition 3, the Medicaid Expansion Initiative, will be on the state’s ballot in November.

In Nebraska, The Fairness Project contributed more than $1 million between March and June of this year to Insure the Good Life, the local campaign group advocating for expansion.

Aside from financial assistance, The Fairness Project also helps with campaign strategy, polling, legal research and staffing.

“They were so successful in Maine that they’ve been a great resource in navigating the ballot initiative waters,” said Meg Mandy, campaign manager for Insure the Good Life.

Advocates submitted 135,000 signatures in June — 50,000 more than required — and expect to hear from state officials this month about whether they are certified to be on the ballot in November.

“They’re familiar with that process, they’re familiar with the issue, and they’ve had a lot of lessons learned,” Mandy said about The Fairness Project. “A lot of successes in Maine have been helpful to us as we try to move this forward in Nebraska.”

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The key, Schleifer said, is forming relationships with groups on the ground that have been fighting for Medicaid expansion for years, and investing in resources early on.

“The sooner we start, the earlier we can help these grassroots organizations get these campaigns off the ground, the better the campaign will be, and the more we can engage with voters,” he said.

But Schleifer made it clear that The Fairness Project’s goal is not to step in and take over.

“It’s their state, it’s their work, it’s their campaign,” he said. “We tap into the understanding of what they want to see, what they’ve been through.”

With just a few months until Election Day, Schleifer is confident the state campaigns will be victorious.

“We just know how popular these issues are with voters,” he said.

But the campaigns have faced opposition from conservative and libertarian groups that argue expanding Medicaid is fiscally irresponsible, and that out-of-state groups like The Fairness Project shouldn’t be involved in local issues.

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“This fall, the Fairness Project will be joined by other special interests to pass Medicaid expansion,” Wayne Hoffman, leader of the Idaho Freedom Foundation, wrote last month in a blog post. “Hospitals, doctors, labor unions, and business lobby organizations will collectively spend an easy seven figures to convince Idaho voters to expand Obamacare in Idaho, easily dwarfing the efforts of Medicaid expansions volunteers.”

Schleifer countered that any campaign requires money to be successful.

“To do anything in politics or policy you need resources,” he said. “We want to make sure that local groups do not miss out on the opportunity to run a race like this because they don't have the resources.”

The Fairness Project is in discussions with advocates in other states that haven’t expanded Medicaid, for potential campaigns starting in 2019.

Schleifer declined to specify which states, but there are only six states left that haven’t expanded Medicaid and allow for citizen-led ballot initiatives: Florida, Missouri, Oklahoma, South Dakota, Mississippi and Wyoming.

“We’re certainly looking to ’19 and ’20, and any state that has a ballot process and hasn’t expanded Medicaid, we would love to talk to them and work with them,” he said. “Since legislatures have failed to expand Medicaid, they’re failing their constituents, and we’re there for those voters if they want to try to put Medicaid expansion on the ballot.”