Even in the states that just voted to expand, GOP lawmakers are considering work requirements and other conservative policies that would curtail enrollment. | Joe Raedle/Getty Images health care Medicaid expansion supporters already looking toward 2020 ballots

The California union that provided major funding for successful ballot campaigns to expand Medicaid in three red states this year is already looking for where to strike next to expand Obamacare coverage in the Donald Trump era.

Leaders of SEIU-United Healthcare Workers West declined to identify which states they might target in 2020. But the six remaining states where Medicaid could be expanded through the ballot are on the group's radar: Florida, Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.


“This past election teaches us that this can be passed anywhere,” said Dave Regan, president of the UHW, which represents 100,000 nurses and other caregivers in California and provided most of the funding for the expansion campaigns in Nebraska, Idaho and Utah this year and Maine last year. “We’d love to do it everywhere. That’s ultimately the goal.”

Officials at the Fairness Project, the progressive advocacy group the UHW created in 2015 to spearhead these and other ballot campaigns, said this year’s health care-fueled blue wave marked a turning point for the Affordable Care Act — and Medicaid expansion in particular.

Still, many of the biggest states that have refused Obamacare’s coverage expansion for low-income adults, including Texas and Georgia, are legally barred from putting the question directly to voters. And many Republican leaders remain staunchly opposed to the program.

In Wisconsin, where Democrat Tony Evers toppled Gov. Scott Walker after campaigning on Medicaid expansion, GOP lawmakers are vowing to block the program. In Georgia, where the governor’s race remains undecided, Republican Brian Kemp routinely rails against it as an unaffordable “government takeover of health care.” Oklahoma Gov.-elect Kevin Sitt opposes expansion and is calling for cuts to the state's existing program, which is among the stingiest in the nation.

Even in the states that just voted to expand, GOP lawmakers are considering work requirements and other conservative policies that would curtail enrollment.

Lawmakers from remaining holdout states also say any campaign sponsored by a California union would face skepticism.

“Oklahoma would probably be their most difficult target, because it’s California,” Sen. Jim Inhofe (R-Okla.) said. “No one has any respect for California and what they have done. For that reason, they should save the tough ones for last.”

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The Fairness Project argues that this year’s initiatives were successful because local organizers ran good ground campaigns, got buy-in from some Republican officials and portrayed the issue as nonpartisan — not an easy task, given longstanding GOP promises to repeal Obamacare. The stigma of union money wasn’t a major obstacle in red states this year, group officials said, where they succeeded in passing several minimum wage hikes in addition to Medicaid expansion.

“If you want to accuse us of caring for tens of thousands of people and wanting to get them health care, well, we're guilty of that,” said executive director Jonathan Schleifer.

In all, the Fairness Project spent $6 million on the three Medicaid campaigns. The group and UHW declined to say how much came from the union, versus small donors, though the UHW says it was a "major contributor."

Now, the Fairness Project is starting conversations with groups in states that may attempt to put the question to voters in 2020. Though officials declined to name the states, progressive advocacy groups in Florida and Oklahoma confirmed to POLITICO they reached out to the Fairness Project asking how to pursue their own expansion ballot measures.

“When we see California or Massachusetts do things, we think: ‘That’s great, that’s good for them, but those lessons don’t translate back here,’” said Carly Putnam, policy director for the Oklahoma Policy Institute, a progressive think tank. “But seeing that everyday Utahns and Nebraskans pulled the lever for Medicaid expansion, in states not known for having robust safety net programs, is really encouraging. We would definitely be interested in working towards this here.”

Vicky Neapolitan-Scott, a Pensacola-based social worker and leader of the electoral activist Indivisible chapter in northwest Florida, said she was also inspired by the success of the Medicaid expansion initiatives to reach out to the Fairness Project.

“Watching it pass in Nebraska, Utah and Idaho gave us a lot of hope for getting it passed here,” she said.

If Republican gubernatorial candidate Ron DeSantis prevails in the ongoing Florida recount, that would likely take Medicaid expansion off the table for at least four years — unless voters approve it through the ballot in 2020. Florida ballot standards are tougher than most, since the state requires 60 percent of voters to approve an initiative. But Florida health care advocates say this year’s ballot measure restoring voting rights for 1.4 million ex-felons, which passed with 64 percent support, is a hopeful sign for a Medicaid expansion referendum to cover more than 600,000 in the state.

“It showed we can get an initiative for a progressive policy on the ballot and make a nonpartisan argument for it,” Neapolitan-Scott said. “I think we could do the same for expansion.”

To bring Medicaid expansion to other holdout states, the Fairness Project said it wants to use the same battle plan that’s already worked elsewhere. That involves searching for states with the right elements in place, bringing in millions in funding and an army of staffers to conduct polls, gather the signatures to get the question on the ballot and campaign hard for passage. Schleifer, the executive director, emphasized that the collaboration with local groups requires a “long runway” — beginning at least a year before the election takes place.

“We look for where there is already a ton of support on the ground, build bipartisan in-state coalitions, and provide the resources they need to get on the ballot,” he said. “Because we know that good policy ideas and strong grassroots support isn’t always enough to win an election.”

That was the case in Nebraska, where Democrats in the minority in the state legislature had for years waged a fruitless battle to pass an expansion bill. State Sen. Adam Morfeld, who introduced two failed measures, said he reached out to the Fairness Project last November on the same night Maine voters became the first in the country to approve Medicaid expansion through the ballot.

“They provided more than a million dollars in seed funding to help collect the signatures, which demonstrated to our local folks on the ground that we were organized and serious and encouraged them to contribute,” Morfeld said.

In other states, including Utah, the Fairness Project reached out first to make the case.

“At first we said, ‘Are you crazy? In Utah we just don’t do ballot initiatives,’” said RyLee Curtis, with the pro-expansion advocacy group Utah Decides Healthcare. “We were very skeptical at first, because we have one of the highest signature thresholds in the country. But the Fairness Project did early polling specifically on a ballot initiative to show it was possible, finding about 60 percent support.”

In all three states this year, the Fairness Project poll-tested and deployed an effective “hybrid message” that emphasized both Medicaid expansion’s fiscal benefits for state budgets and health benefits for individuals and families. The campaign worked to counter messages from conservative policymakers opposing Medicaid expansion, who have long cautioned it would be an unaffordable entitlement that would crowd out state funding for education and other public priorities.

“We focused on showing people how their friends and neighbors would benefit,” Schleifer said.