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LEADORE, Idaho — In this postage-stamp-size town nestled in the remote mountains of eastern Idaho, Merrill Beyeler and his family operate a ranch where some 800 head of cattle graze against the backdrop of wide-open blue skies and serene silence.
It’s as rural as rural gets in America, 116 miles from the nearest “big” city, Idaho Falls, and a seemingly unlikely place to find support for the expansion of a government program like Medicaid.
But Beyeler, a long-time Republican and former state legislator who was hardly a fan of Obamacare when it passed, has become an advocate for Idaho’s Proposition 2, which aims to expand Medicaid eligibility across the state and "close the gap" of people without health care coverage.
"If you want to look where Medicaid expansion can play a significant role, it's in our rural areas, no question about it," Beyeler said on a recent day at the ranch, noting that many of those without health care "are people that are in animal production — that’s ranchers, crop production, those that are in construction, those that are in hotels, those type of folks."
Voters regularly cite health care as their top issue across the country in this midterm election, and Idaho is one of four rural, Republican states this year where this kind of access to health care is directly up for a vote.
Advocates are trying to bypass Republican state legislatures and pass a Medicaid expansion through ballot initiatives in Idaho, Utah and Nebraska, and to extend the current expansion in Montana that’s otherwise set to sunset.
And if expansion is to pass in these states in November, it will have to be with support from people who would otherwise consider themselves conservative, like Beyeler.
He says the issue became personal when one of his sons fell into the coverage "gap" — the group of people who make too much money to currently qualify for Medicaid, but also make too much to earn affordable subsidies on the state exchange. His views on the issue go beyond his own family’s situation, however.
"As soon as you began to look at it realistically, you began to do the fact-finding, you begin to look at all the numbers and those kind of things, all of a sudden you begin to change your position, and that’s what we need to do."
Expansion of Medicaid, the government-run health care program for low-income Americans, was initially born out of the Affordable Care Act, and a 2012 Supreme Court ruling that left the decision to expand to the states.
So far, 33 states and the District of Columbia have opted to go through with the expansion, which initially included individuals earning up to 138 percent of the federal poverty level to be fully covered by the federal government. That coverage will eventually drop to 90 percent, with states left to make up the rest.
Montana's initiative proposes to finance that gap by raising taxes on tobacco products. In Utah, it's a proposed 0.15 percent increase to the sales tax.
The number of people potentially directly affected by an expansion could be considerable.
In Idaho alone, up to an estimated 91,000 people could sign up for Medicaid if enacted. If it happened in all four states, that number could reach roughly 400,000.
In Idaho, those campaigning for the initiative found creative ways to draw attention to their cause.
Luke Mayville, who co-founded the pro-expansion group Reclaim Idaho, has been driving around visiting all 44 of the state’s counties in a gigantic green RV with the words “Vote Yes For Medicaid” painted across it.
Sitting behind the wheel on one recent leg of its journey between Bonneville and Bingham counties, Mayville said the loud-looking RV makes people "start to pay attention, and then once they are paying attention, you can engage them in a powerful conversation about the health care crisis."
Mayville is optimistic that support for the initiative will be able to break through the partisan lines usually drawn in major debates around health care from the state legislatures to the U.S. Capitol.
"It really is not a Republican-Democrat issue," he said after moseying through a diner in Idaho Falls and chatting about the initiative with tables of strangers. "No one brought up the partisan divide, no one brought up who the president is or who the president used to be."
The effort has also had some help from a progressive, Washington-based nonprofit called the Fairness Project, which has offered legal and logistical assistance to campaigns in all four states, and is driving the ballot initiative strategy as a new frontier in the national fray over health care. They’ve sent significant financial help, including at least $1.3 million to Nebraska, $2.7 million to Utah, $400,000 to Montana, and $500,000 to help get the Idaho proposition on the ballot.
"The movement to expand access to health care is the most powerful force in American politics today," said Jonathan Schleifer, the Fairness Project’s executive director.
Though he also added, "grassroots enthusiasm alone isn’t enough to get on the ballot and win, and that’s where we come in."
Ballot initiatives have also been backed by state hospital associations and other medical care providers — who see expanding medicaid as a way to provide better care to vulnerable patients — and make sure they are paid for their efforts.
The most significant opposition to these ballot questions, at least financially, has come in Montana, where the tobacco industry has thrown more than $8 million into fighting the measure.
But in Idaho, Nebraska and Utah, organized opposition to the expansion ballot initiatives is minimal, political operatives in each of the states say.
The Idaho Freedom Foundation, a conservative public policy foundation based in Boise, has argued that expansion would encourage able-bodied people not to work, that Medicaid is already too large and that it could bust the budget. But they haven’t had the means to broadcast their message as widely as proponents have theirs.
"Crony interests in big medicine have put a fortune, they put half a million dollars," said Fred Birnbaum, the foundation’s vice president. "They have the money for the ads. We would love to run ads, but the opposition doesn’t have the funds."
In Nebraska, the state’s Republican Gov. Pete Ricketts issued a statement opposing expansion but has spent little political capitol fighting it. There, Americans for Prosperity have taken the lead in opposing the ballot initiative, but a spokesperson for the conservative organization told NBC News they were being outspent by the bill’s proponents and had so far run only some digital advertising.
In Utah, the GOP-controlled state legislature passed an alternative plan earlier this year, spearheaded by the governor, and supported by Mitt Romney — the Republican senate candidate and former presidential candidate who remains the state’s most popular political figure.
But there as well, organized opposition to the Medicaid expansion initiative has been limited, with GOP organizations and the powerful Mormon Church focused instead on fighting an initiative to expand access to medicinal marijuana.
Polling in all three states is limited, but Republican political operatives in each told NBC News they expected the measures to pass.
If any of the measures do indeed pass, their ultimate future is far from certain.
For example, the Maine expansion, the first of its kind that passed in 2017, has been entangled in the courts since Republican Gov. Paul LePage has refused to implement it, and it’s still possible there could be other legal challenges if any of the new initiatives are approved.
Questions over funding might linger in states like Idaho, where the ballot wording did not specify how the state would address any future increased costs.
Still, if a wave of Western voters approve of these initiatives, advocates plan to use that to push forward even more.
"If we see four red states vote for Medicaid expansion," said Schleifer, "we are in a much better position to push for expansion in the remaining states."