For nearly a decade, opposition to former President Barack Obama's health care law has been a winning message for Nebraska Republicans.
It's helped them win every statewide office, control the Legislature and hold all the state's congressional seats. So it was something of a surprise for Bob Tatum when he set out to ask his fellow Nebraskans if they would back a ballot initiative to expand Medicaid, one of the pillars of Obama's health overhaul.
"There seems to be a lot more support than I anticipated," said Tatum, who lives in a remote town near the Colorado border.
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It took him little more than a week to gather over 100 petition signatures in Perkins County, where roughly 70 percent of the 1,963 registered voters are Republicans. Tatum, 66, also is a Republican but differs from most of his party's elected officials. He supports the Medicaid expansion because his job as an ambulance driver brings him into frequent contact with working people who can't afford insurance but earn too much to qualify for regular Medicaid.
"When I was circulating petitions, pretty much everyone signed it without objection," Tatum said. "I didn't expect that to be the case in rural Nebraska."
Nebraska isn't the only conservative state where residents are bypassing a legislature that has refused to expand Medicaid.
Voters in two other Republican-dominated states, Idaho and Utah, also will decide in November whether to expand the health insurance program to more lower-income Americans. Another ballot initiative, in Montana, seeks to raise a tobacco tax to keep funding a Medicaid expansion that is set to expire.
It also has become a focal point in numerous governor's races.
The election-year push in conservative-leaning states for one of the main aspects of Obama's health care law has surprised many Republican lawmakers after they spent years attacking it.
Most GOP lawmakers in Idaho staunchly opposed expansion efforts there and cast it as a welfare program that would deepen the state's reliance on the federal government. Supporters responded by gathering more than 75,000 petition signatures, far exceeding the minimum threshold to qualify for the ballot.
Expansion advocates launched a petition drive in Utah after continued resistance from the Republican-dominated Legislature. Utah lawmakers did expand coverage to about 6,000 of the state's neediest residents last year and approved another expansion measure with work requirements, but the federal government hasn't yet accepted that plan. Expansion advocates say it still leaves tens of thousands of people without insurance.
Other states have seen Medicaid expansion become a top issue in their governor's race, with Democratic candidates forcing Republicans to defend their opposition.
In Tennessee, Democratic contender Karl Dean argues that the state already has lost out on $4 billion in federal money by refusing to participate.
"That money is being spent in other states," Dean said in a recent debate. "We need to get our Medicaid dollars back here."
His Republican opponent, Bill Lee, noted that Tennessee had expanded its Medicaid program long before Obama was even in office, but rolled it back in 2003 to balance the budget.
"We expanded Medicaid before, and it ended up failing and it almost broke the state," he said.
Democrat Stacey Abrams is promoting expansion as a way to improve health care access in rural parts of Georgia where hospitals have closed, partly due to the expense of caring for the uninsured. Republican Brian Kemp said Abrams wants to "double down on big government programs that cost too much and fail to deliver."
Medicaid expansion also has been in the spotlight in the Florida, Kansas and Wisconsin governor's races.
About 12 million Americans have gained coverage under the expansion in the 33 states that opted for it under the Obama health care reforms. The program extends Medicaid to cover more low-income adults, including those with no children at home, and the federal government picks up most of the cost.
A government report released this past week found that lower-income people in states that did not broaden access to Medicaid were much more likely to skip needed medical care than people in states that did.
In Nebraska, Amanda Gershon is among those who went without.
As a single, childless adult, she wasn't eligible for regular Medicaid after a series of autoimmune disorders in 2013 rendered her too sick to work. The Lincoln resident remained uninsured for two years before she qualified for Social Security disability benefits that allowed her to receive coverage. Even then, the enrollment process took nine months.
Without the prescription drugs, tests and surgeries that could have helped her earlier, Gershon said she suffered needlessly and wasn't able to hold a job.
A co-sponsor of the petition drive to qualify the initiative, she said she grew frustrated with lawmakers who opposed the Medicaid expansion because none of them proposed alternatives that would have helped her.
"It's hard to understand," said Gershon, now 36. "They are there to represent the people, and it does seem like a majority of people see this as a good thing."
Kathy Campbell is among the few Republicans who were not surprised by the citizen effort to circumvent the Legislature. As a state lawmaker, she had pushed repeatedly for Medicaid expansion before being termed out of office last year.
"People want good health care policy," she said. "They're much more informed about it than you might think. I think that's why you had so many people sign the petition."
Politicians who steadfastly opposed the Medicaid expansion in Nebraska say the initiative's supporters don't understand the consequences.
"I don't believe anybody (in the Legislature) who voted against it is really opposed to helping people," said Sen. Mark Kolterman, a Republican. "But how are we going to pay for it?"
The estimated annual cost of expanding the program in Nebraska is $40 million to $69 million, roughly 1 percent of the state budget.
State Sen. John Stinner, a Republican who heads a budget committee, cited voter frustration that so many people lack health care as a driving force behind the initiative.
"Believe me, I'm frustrated with it, too," he said. "I don't want to be insensitive to people out there in that Medicaid expansion group. I just don't think this is sustainable."
If passed, the measure would add about 90,000 Nebraskans to the Medicaid rolls. Organizers with Insure the Good Life, a Nebraska group formed to back the expansion, said many of those people work in jobs with no health benefits, such as in hotels, restaurants and construction.
"Almost every single person in Nebraska probably knows somebody who's directly affected by the unaffordability of health care," said Meg Mandy, campaign manager for Insure the Good Life.
Associated Press writers Rebecca Boone in Boise, Idaho, Kimberlee Kruesi in Nashville, Tennessee, and Lindsay Whitehurst in Salt Lake City contributed to this article. Mulvihill reported from Cherry Hill, New Jersey.