Voters in four states that heavily supported President Donald Trump in 2016 have a chance this Election Day to secure health coverage for nearly 400,000 low-income working people.

Organizers in Idaho, Nebraska and Utah successfully gathered enough signatures for petitions to put ballot initiatives in front of voters this year that would expand Medicaid eligibility to include anyone earning up to 133 percent of the federal poverty level , which is about $16,000 a year for a single person and $34,000 for a family of four. Voters in Montana, which adopted Medicaid expansion in 2015, will be able to decide whether to extend the benefit, which is set to expire in the state on July 1.

Residents of these four states have an opportunity to send a signal to Republican officeholders that voters want more health care for their neighbors, at a time when the Trump administration and GOP state officials are hard at work scaling back the reach of the Affordable Care Act and making Medicaid benefits harder to get and keep .

Its no coincidence that all four states are deeply conservative, because its conservative Republican elected officials who have resisted the expansion most strenuously. A similar dynamic is afoot in three other states Florida, Georgia and Wisconsin where Democratic gubernatorial candidates have made Medicaid expansion a central part of their platforms and have real chances to win.

The 2010 health care law enacted by President Barack Obama called for all states to expand Medicaid, but a 2012 Supreme Court ruling permitted states to opt out, which Idaho, Nebraska, Utah and 14 other states have done.

Under the Affordable Care Act , the federal government pays at least 90 percent of the cost of covering newly eligible enrollees, and states must finance the remainder. In states that expanded Medicaid , the uninsured rate fell more than in nonexpansion states. Moreover, the federal dollars going to those states have benefited hospitals especially rural facilities and generated economic activity, including hiring, that didnt happen in nonexpansion states.

Maine voters last year approved a ballot initiative to expand Medicaid the first time that method was used to increase health coverage under the ACA expansion. Gov. Paul LePage (R), however, has thus far refused to implement it , despite court orders. Because the state legislatures in Idaho, Montana and Nebraska would have to appropriate the funding for Medicaid expansion, its possible lawmakers could defy the will of the voters even if the measures pass. In Utah, the initiative would simply take effect.

The success of the Maine ballot initiative inspired activists in other states to attempt the same maneuver. Volunteers and paid organizers in Idaho, Montana, Nebraska and Utah crisscrossed their states collecting signatures from voters who wanted a chance to back the expansion at the ballot box. That was no mean feat in those conservative states, which have laws governing citizen initiatives that make it difficult to get them approved for the ballot.

After piloting the strategy of expanding Medicaid via ballot initiative in Maine in 2017, were testing whether it can work in four states that Trump won by an average of more than 20 percentage points, said Jonathan Schleifer, the executive director of the Fairness Project, based in Washington, D.C.

The Fairness Project is a labor-backed organization that offers financial support and logistical assistance to grassroots groups around the country promoting direct democratic action on issues like Medicaid expansion and minimum-wage increases. Their legislatures have been an obstacle to that, and now they have a tool to actually expand Medicaid in spite of the wishes of their legislatures, Schleifer said.

If we can win in these states, we can win anywhere, because what weve seen in health care is the biggest gap isnt between Republicans and Democrats. Its between the politicians and everyone else, Schleifer said. The Fairness Project is talking with organizers in other red states about more Medicaid expansion initiatives in 2019 and 2020, he said.