If it wins approval here, it could happen almost anywhere.On Nov. 6, Utah voters will consider a ballot measure that would expand Medicaid to cover up to 150,000 more people under the Affordable Care Act.

Two other conservative states, Idaho and Nebraska, will also vote that day on Medicaid expansion proposals.

The states, if the measures pass, would join more than 30 others that have expanded Medicaid under the 2010 health care law. In all three states, advocates are trying to outflank Republican lawmakers who have blocked expansion efforts.

The Utah push is five years in the making. State politicians and advocates have tried repeatedly, by one means or another, to expand Medicaid. Gov. Gary R. Herbert, a Republican, and his team have spent countless hours in negotiations with the Obama and Trump administrations. In 2015, the state Senate passed a bill, but it never reached the floor of the state House of Representatives.

Now, supporters of expansion are cautiously optimistic. Opinion polls suggest that 60 percent of Utah adults favor it. Advocates are energetic and well organized, knocking on doors and speaking frequently at public events. Opponents are lying low, but plan to make their case more forcefully before Election Day.

On a recent Sunday, a big blue banner hung inside First United Methodist Church here in Ogden, urging people to vote for the ballot measure.

“Jesus was constantly healing people,” said the Rev. Kim James, the pastor, whose sermon cited examples from the Gospel of St. Mark. “I’ve been volunteering my time and effort to this cause, Proposition 3, because I believe Jesus cared deeply about people’s health. He didn’t ask, Do you have your insurance card? Did you pay your co-payment and your deductible?”

Among the most effective advocates for the proposal are people like Christie Sorensen, 28, who applied for Medicaid after a fast-growing tumor infiltrated her chest and surrounded her heart.

“Medicaid saved my life,” she said. “Expanding it can save many more.”

State Rep. James A. Dunnigan, a Republican who is co-chairman of the Health Reform Task Force in the state Legislature, said he would not vote for the Medicaid ballot measure, but he added: “It’s likely to pass. There is very little organized opposition.”

While there has been little vocal opposition to expansion so far, Republicans in the Utah Legislature worry about costs and note that enrollment far exceeded expectations in some states that expanded Medicaid. The expansion “could ultimately require even greater tax increases, or spending cuts to things like education, other programs for the needy, roads and public safety,” said a statement of opposition drafted by Republican state legislators.

Heather Williamson, the Utah director of Americans for Prosperity, the conservative group funded by the brothers Charles G. and David H. Koch, said: “We are ramping up our efforts against the ballot initiative. We are very concerned that it will lead to out-of-control spending and create a welfare trap for able-bodied adults.”

The federal government would pay at least 90 percent of the costs for newly eligible beneficiaries, contributing roughly $800 million a year. To pay the state’s share, estimated at $90 million a year, the ballot measure would increase the state sales tax rate to 4.85 percent, from the current 4.7 percent.

“The additional tax, on nonfood items, equates to about a penny on the cost of a movie ticket,” Stacy Stanford, a health policy analyst at the Utah Health Policy Project, a nonprofit advocacy group, told an audience of 350 people at a recent forum for federal and state candidates in the Salt Lake City area. “We are asking voters to make a decision if it’s worth an extra penny to provide health care to 150,000 Utahns in need.”

Medicaid has become a driving force in U.S. health care, in part because of the expansion of the program under the Affordable Care Act. The expansion started with 26 states in 2014, and several have come on board since then. Texas and Florida are the biggest holdouts. Republicans in Congress tried last year to roll back the expansion and were surprised to see the degree of public support for the program.

Under the Utah ballot initiative, Medicaid would cover adults with annual incomes up to 138 percent of the poverty level — up to about $16,750 for an individual.

By contrast, the state Medicaid program now covers parents with incomes up to 60 percent of the poverty level, or about $7,300 for an individual. The state has also extended coverage to about 3,000 adults with income below 5 percent of the poverty level — about $600 a year — who do not have dependent children but are “chronically homeless” or need substance abuse or mental health treatment.

Utah officials estimate that 100,000 to 150,000 people would gain Medicaid coverage if voters approve the ballot measure. Monthly enrollment now averages 280,000, so the proposal would increase the number of people on Medicaid by roughly one-third to one-half.

“Polls suggest that the ballot measure is likely to pass,” said Andrew Croshaw, chief executive of Leavitt Partners, a health care consulting firm founded by former Gov. Michael O. Leavitt of Utah, a Republican who served in the George W. Bush administration. “If it fails it will be close. It could pass easily. So far we have not heard many opposing voices. But the public debate is just beginning.”

The Republican-controlled Utah Legislature voted this year for a more limited expansion of Medicaid, which would extend coverage to 70,000 to 90,000 people with annual incomes up to 100 percent of the poverty level, or $12,140 for an individual. The state law also calls for work requirements and would allow the state to freeze enrollment if it did not have money to care for all those made eligible for Medicaid.

This is not what Congress envisioned in the Affordable Care Act, but Utah still wants the extra federal funds available to states that fully expand Medicaid.

Utah has asked the Trump administration for a waiver to permit the “partial expansion” of Medicaid. White House officials, who oppose any expansion of “Obamacare,” have resisted the idea, leaving Herbert, the governor, in an awkward position. He had been hoping by now to have federal approval for his preferred alternative to the ballot initiative.

Paul Edwards, a deputy chief of staff to Herbert, said the governor “fully understands the frustration of voters” who have been paying higher taxes under the Affordable Care Act without receiving the benefits of expanded Medicaid.

“There is no active campaign against the initiative on our part,” Edwards said. But, he added, the governor “is concerned about the long-term viability” of a full Medicaid expansion and the proposed sales tax increase, and would prefer to see a more limited expansion of the program with “appropriate cost controls.”

One major force in Utah, the Church of Jesus Christ of Latter-day Saints, has not taken a public position on the ballot measure. But a church management employee, David C. Heslington, in a recent letter to The Deseret News, expressed his personal support, saying that a “yes” vote on Proposition 3 would “offer a merciful hand to Utahns in need.”

Utah residents take pride in their reputation as the most charitable state, measured by giving as a percentage of income.

“We are a conservative state, but very compassionate,” said Charles Dubenezic, a retired college professor in Eden, Utah, near Ogden.

Charity is a priority for the Mormon Church, which provides food, medicine and financial assistance to many of the needy. But people recognize the limits of such “church welfare.”

“The church tries to do all it can, but can’t take care of a major chronic or catastrophic illness,” said Reed E. Harris, a former bishop in Salt Lake City. “The purpose is to help people for a short time, until they get work and can be self-sufficient.”

Stephanie M. Burdick, 30, who lives in Salt Lake City, remembers going around rural Arkansas with her father, a Mormon bishop, tending to the needs of local church members who had fallen on hard times.

She suffered a traumatic brain injury in a surfing accident in 2015. When she woke up in the hospital, her life was changed: She had little ability to walk, talk or feed herself.

“Utah denied me Medicaid,” Burdick said. “They told me that if I was a mother, a parent, I would be able to get Medicaid. But as a childless adult, I could not. I was told to call my local bishop. I don’t know how I’m supposed to ask the bishop to pay my medical bills.”

She faced thousands of dollars in bills for doctor’s visits, neurological tests, prescription drugs, rehabilitation and different types of therapy. She eventually qualified for Medicaid, after agreeing to spend a significant amount of her limited income on her medical care.

Burdick has become an advocate for Medicaid expansion. It is, she said, “in alignment with Utah values.”

This article originally appeared in The New York Times.

Robert Pear © 2018 The New York Times