After a car accident left her saddled with medical debts, Stacy Stanford found work as a disability-rights activist. A big part of her job is canvassing in support of Proposition 3, a ballot initiative that could expand Medicaid benefits to a hundred and fifty thousand more Utahans.
In 2010, Stacy Stanford and her husband were driving to a friend’s house in Salt Lake City when another car collided with theirs. The Stanfords’ car was totalled; the couple walked away with seemingly minor injuries. But soon Stanford, who was then working as an activities director for patients with Alzheimer’s, began to experience backaches. These were followed by debilitating pain in her hips and legs. She started having difficulty walking, which led to her losing her job, a year later, and her health insurance along with it.
A few months before the accident, President Barack Obama had signed the Affordable Care Act. Under the new law, Stanford would qualify for Medicaid. (With giddy fascination, she downloaded a PDF of the Affordable Care Act and read all nine hundred–plus pages on her Kindle.) In 2012, however, the Supreme Court ruled that it was up to the states to decide whether they would accept federal dollars to expand their Medicaid programs under the A.C.A.; in 2013, the Utah state legislature, dominated by Republicans, rejected Medicaid expansion (and also passed a law prohibiting the governor from expanding Medicaid without the legislature’s approval). The vote affected approximately a hundred and thirty thousand Utah adults. Stanford was devastated.
About a year after that decision, Stanford appeared in a short documentary, called “Entitled to Life,” about vulnerable Utahans who were denied Medicaid coverage. She still lacked a diagnosis for the expanding list of symptoms she had developed after the wreck: vision and hearing loss, cognitive and memory problems, and episodes of partial paralysis. She began to suffer from daily migraines, which often confined her to bed. Under the A.C.A., adults earning less than seventeen thousand dollars per year qualify for Medicaid; without expansion, however, the amount is substantially lower, and eligibility requires an additional qualification, such as pregnancy or a proven disability. Stanford, who began selling jewelry and crafts after she lost her job, could not provide documentation of her medical challenges because she could not afford the necessary brain scans and visits to specialists. “I’m trying to work as a disability activist,” she said in the film. “And I could do so much more on behalf of my peers if I could get out of bed in the morning.” By then, her medical bills topped two hundred thousand dollars.
Stanford was studying social-justice movements and connecting with other disabled people online. From studying the aids advocacy organization act up, she learned to “keep the focus on patients and elevate their stories,” she told me during an event held by the advocacy group Voices for Utah Children at the Marriott in downtown Salt Lake City. Last year, after four years of volunteering, Stanford joined the staff at the Utah Health Policy Project (U.H.P.P.), a group that advocates on behalf of uninsured and underserved Utahans, as a health-policy analyst. For the first time in years, she was able to purchase health insurance, which she got through the state exchange established under the Affordable Care Act. Now thirty-three years old, Stanford still suffers from chronic pain and cannot walk without a wheelchair or crutch. But her insurance enabled her to visit a neurologist who developed a treatment plan for her migraines, and that has been “the biggest key to getting a job, honestly,” Stanford said. (She still screens her calls for debt collectors, and said that she intends to declare bankruptcy because of her unpaid medical bills.)
A major component of Stanford’s current job is canvassing for a ballot initiative that would expand Medicaid to approximately a hundred and fifty thousand more Utahans and bring an estimated eight hundred million dollars in tax revenue back to the state. Thirty-three states have accepted this arrangement since 2010; Utah is one of seventeen that have not. In recent polling, sixty-five per cent of voters in the state say that they support the ballot initiative, known as Proposition 3. Polls show strong public backing for similar initiatives on the ballot this fall in Idaho and Nebraska; Montana will also vote on reauthorizing its Medicaid expansion.
Stanford believes in what she calls a “testimony of kindness,” drawn in part from her upbringing in the Mormon Church. She rarely adopts aggressive tactics in her activism, instead favoring storytelling and earnest communication. Last summer, however, when members of Congress, including Senator Orrin Hatch, of Utah, were considering a plan to repeal and replace the A.C.A., she helped organize a protest in downtown Salt Lake City, in which disabled people parked their wheelchairs in the street. For about thirty minutes, the group blocked traffic, forcing buses and trucks to turn around. At one point, an octogenarian in an electric wheelchair gave the signal to unfurl ninety feet of banners that Stanford and her husband had created. Together, they read, “Senator Hatch, Don’t Kill Us!”
Leaders from the U.H.P.P. and other advocacy groups, such as Voices for Utah Children and the A.A.R.P., had wondered aloud for years if they should organize around ballot initiatives. “Utah is not a ballot-initiative state,” Matt Slonaker, the executive director of the U.H.P.P., said. “It’s a state where you don’t want to upset the balance. You elect your leaders, and they do the work for you. Your leaders are members of the community and probably go to church with you, too.” The last time Utah voters approved a ballot initiative was more than a decade ago, in 2007.
In 2017, Slonaker helped to convene dozens of groups dedicated to gathering signatures and campaigning for what became Proposition 3. A national nonprofit known as the Fairness Project provided guidance, data modelling, and financial backing. “Ballot initiatives are probably the most undervalued investments in progressive politics,” Jonathan Schleifer, the executive director of the organization, said. The Fairness Project has supported successful ballot initiatives to raise the minimum wage in Arizona, Colorado, Maine, and Washington State, in 2016, and to expand Medicaid in Maine, in 2017. The group is also backing the current efforts to raise the minimum wage in Arkansas and Missouri, to expand Medicaid in Idaho and Nebraska, and to reauthorize expansion in Montana.
Meanwhile, thirty-seven Republican state legislators in Utah have formally opposed the ballot initiative. Representative Robert Spendlove, a Republican and outspoken critic of the A.C.A., argues that Proposition 3 is fiscally irresponsible and “exposes Utah to great risk and uncertainty.” He contends that Medicaid costs are likely to squeeze out state spending on other priorities, such as education and public safety. “This initiative would leave taxpayers with a program on autopilot, a zombie program that would be financially devastating to our state,” he has written.
Academic research paints a brighter portrait. Hundreds of studies now document the effects of Medicaid expansion, often drawing on comparisons between states that have expanded the program and those that have not—a “natural experiment,” as Schleifer puts it. Expansion is associated with sharp declines in the numbers of uninsured people, lower rates of infant mortality, and higher rates of early cancer detection. It is linked to reductions in medical debt, bankruptcy filings, and evictions. It lowers the likelihood that hospitals will close in rural areas. It increases the chances that disabled adults will be employed. It boosts local job creation in health care, retail, and construction. An analysis of Medicaid expansion in Michigan, published in The New England Journal of Medicine, documented a reduction in state spending on mental-health and other care for prison inmates, and showed that the infusion of federal dollars into Michigan’s economy created a multiplier effect that spurred large increases in income-tax and sales-tax revenue.
Norman Waitzman, the chair of the department of economics at the University of Utah, told me that the benefits of Medicaid expansion are self-evident. “Basically, this is getting boring for an economist,” he said.
Karina Andelin Brown is a stay-at-home mother in Cache County, a conservative, rural district north of Salt Lake City. She decided to run for the Utah House of Representatives this year, as a Democrat, largely to promote Medicaid expansion. Her own mother, who worked full time and raised seven children, could not afford health insurance and died, of a stroke, in 2013, nine months before she would have qualified for Medicare, at age sixty-five. “I feel that, with quality primary care, her life could have been prolonged,” Brown told me.
By 2014, Utah’s governor, Gary Herbert, a Republican, seemed ready to accept a modified form of Medicaid expansion. His Healthy Utah plan would have allowed tens of thousands of people to qualify for the program and enabled the state to reclaim hundreds of millions in tax dollars from the federal government. The plan passed the State Senate, but it failed in the House of Representatives. During the debate over Healthy Utah, in 2015, Brown said, she e-mailed every member of the Utah House to express her support for the bill. One of them, Ray Ward, a Republican who also supported expansion, called her and encouraged her to step up her political engagement. (Ward, a family physician, is the lone Republican representative to endorse Proposition 3.)
Brown’s election campaign faces long odds—Cache County has not elected a Democrat to the state legislature in decades, and it has never elected a woman. But Brown said that she is motivated largely by the chance to promote Proposition 3. She had knocked on hundreds of doors and has found that “people are receptive to it,” she said. “One of my neighbors, who’s a Republican, she asked me the other day, ‘Why wouldn’t we want to help people?’ ”
Utah is one of the reddest states in the country. It has not supported a Democrat for President since 1964. “It’s almost like a coming-out thing,” Stanford said, of being a Democrat in Utah. She and her U.H.P.P. colleague Courtney Bullard were in Liberty Park, just south of downtown Salt Lake City. A few weeks out from Election Day, Stanford and Bullard were entering a whirlwind of canvassing events, roundtables, and phone calls. They were preparing to talk with the Salt Lake City Tribune’s editorial board and were recruiting volunteers for phone banks to get out the vote for the ballot initiative.
Bullard’s father is a Democrat and in a stake presidency in the Mormon Church, a position that involves oversight of multiple congregations. “My dad has been made fun of for so long,” she said. “People ask him, ‘Do you believe in gay marriage? Do you believe in abortion?’ And he’s, like, ‘Well, I believe in the Church, but I also believe in Democrat values.’ ” These include access to health care, Bullard said.
“Utahans are so compassionate—even the conservatives,” Stanford said, leaning on the blue metallic crutch she often uses in lieu of a wheelchair. They want to take care of their neighbors, “it’s just that sometimes they have blind spots.” Health care is different, though, Stanford said. “Not only Democrats get sick. This is a purple issue.” Bullard nodded. The two friends spend most of their waking hours together, and they lean easily into their pitch.
They approached a playground, newly renovated and bustling with children. Toddlers rode scooters, older kids swung upside down, and xylophone music filled the air, thanks to a boy wielding an oversized mallet. Stanford asked a woman in a long floral skirt, named Samantha Poth, if she had heard of Proposition 3—she hadn’t—and proceeded to explain the rationale behind the ballot initiative. Poth brightened. “I was on Medicaid when I had my daughter,” she said. “When she was born, I had one month to get everything done before I was kicked off, and then I was uninsured.”
“That’s the hole we’re trying to close,” Stanford told her.
Poth said that her stepfather had a brain injury that prevented him from working, but, when he applied for coverage as a disabled person, he was denied.
“The government never considered me disabled, either,” Stanford said. “I was using a wheelchair full time, and the government was, like, ‘No, you’re fine.’ We’re trying to simplify that. So if you’re poor enough, that’s good enough” to qualify for Medicaid, she said.
Poth took a flyer. She explained to Stanford and Bullard that she didn’t usually vote in midterm elections, because she never felt she knew enough about the issues. But this year, she said, would be different.