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Health care advocates in Missouri are closely watching successful efforts to put Medicaid expansion on the ballot in other red states.

Last year, voters in Maine approved expanding Medicaid through a ballot initiative, the first state to gain approval through a public vote.

On Tuesday, the Idaho secretary of state certified petitions to put Medicaid expansion on the ballot in November.

And Nebraska activists gathered more than 133,000 signatures to put a measure on the November ballot in that state; 85,000 were needed.

The result in Missouri is a renewed optimism, albeit cautious, representing a shift in sentiment from previous years in which advocates worked — and failed — to convince lawmakers to expand the health care program for the poor.

Some advocates confirmed there were conversations taking place about how to expand the program, but they would not talk about plans.

“There is a sense that it might be time again in Missouri,” Amy Blouin, executive director of the Missouri Budget Project, told the Post-Dispatch.

“I don’t think it’s going to happen overnight. People are waiting to see what happens in other states.”

Bypassing state legislatures and taking the issue directly to a vote by residents is what has been happening.

In Maine, although 59 percent of voters approved expanding Medicaid, the governor is refusing to implement it.

He said he’d rather go to jail than put the state in “red ink,” according to the Portland Press Herald. The governor’s comments come after a court ruled his administration has to begin the program so newly eligible residents can gain coverage.

A group in Utah is forging ahead in its efforts to put expansion to a public vote.

“Maine certainly served as a bellwether for whether or not this could be done,” said RyLee Curtis with Utah Decides Healthcare.

Fourteen states have so far declined to expand Medicaid, which was part of the Affordable Care Act.

States were never supposed to have an option on expansion. It was mandated until the Supreme Court in 2012 gave states the power to choose.

That decision has created inequity among states, an issue that has resonated with voters, Curtis told the Post-Dispatch.

“Interestingly, Medicaid has always polled pretty well, but there is no question public awareness about the importance of Medicaid is at an all-time high,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University.

“I attribute that to the Republican efforts in Congress to not only repeal the Affordable Care Act but to dramatically cut the program while they were in the neighborhood.”

Expanding Medicaid was designed to decrease the number of people without health insurance.

For example, expanding Medicaid offers coverage to low-income adults without children.

Currently, in Missouri, to qualify for coverage you have to meet income thresholds and be a child, pregnant woman, disabled, a senior, or parent to a child already in the program.

Expansion means extending coverage to those who earn up to 138 percent of the federal poverty level. That means a single Missourian without a child could earn $16,753 and qualify for Medicaid coverage. A family of four could qualify for coverage with a household income of $34,638.

Historically, the program has been critical for access to coverage for children.

Nearly half of Missouri’s children are covered by Medicaid, according to figures with the Missouri Foundation for Health.

But without expansion, many of the country’s working poor find that they earn too much to qualify for Medicaid coverage and earn too little to afford subsidized coverage on the online health insurance exchanges.

Many policy experts refer to this as the coverage gap.

Despite the fact that the federal government would pick up a majority of the funding for the expansion, Missouri’s state lawmakers have declined, citing concern about long-term funding.

Hospitals have warned that forgoing expansion would be detrimental, particularly to rural hospitals that take care of a large share of patients who are uninsured or on government programs such as Medicare.

The Missouri Hospital Association said it was not involved in a new campaign to expand the program but continued to support expansion.

Incoming House Speaker Elijah Haahr, R-Springfield, said expansion was unlikely, at least through the Legislature.

“I don’t see much of an appetite,” he said in an interview.

Meanwhile, all eyes are on November and what voters decide elsewhere.

“Perhaps the ground might be softening,” Jen Bersdale, executive director of Missouri Health Care for All, said in an interview. “Attacks have helped average voters understand what’s at stake.”

“There are a lot of people in the state that are encouraged by seeing what has happened in other states,” she said.

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Samantha Liss • 314-340-8017

@samanthann on Twitter

sliss@post-dispatch.com