Medicaid Expansion

A Grassroots Relational Approach Builds more Power
The Medicaid expansion case studies provide an interesting juxtaposition. Strong partnerships in Nebraska gave the campaign a wide reach and facilitated a successful grassroots volunteer signature process. Montana’s campaign took a more top-down approach that utilized a pay to play model and was more influenced by national organizations and wealthy health care associations.
A Ground Game with Local Knowledge
Initiative 427 was spearheaded by an organization with a deep understanding of Nebraskans’ concerns and strong connections to a network of organizations. The I-185 ballot initiative covered two issues; their ability to effectively educate potential voters and address the unique concerns of Native people and tribal nations around the tobacco tax was key to gaining support from these communities.
Trusting Local Knowledge and Capacity
Trusting local knowledge affords adaptability in the face of one-size-fits-all strategies that are often brought in by outside experts.
Centering Narratives of Directly Impacted People
Nebraska’s campaign was successful because of its personal one-to-one approach and its centering of personal stories.

Building BIPOC Power
While Nebraska is viewed as a largely racially homogenous, white state, a racial justice lens connects the challenges of rural BIPOC communities to those faced by urban BIPOC communities.
Protecting BIPOC Organizers
It is important to anticipate the ways in which racism (or other forms of bias or discrimination) can arise in a campaign’s work and shield BIPOC organizers.
Funding and Timelines Matter
Despite their win, interviewees in both states noted the rushed timelines. More time and funding earlier would have enabled focus on strategy, infrastructure development, and organizing. In Montana, the rush to get ahead of the tobacco industry’s messaging proved fatal to the ballot initiative.
Organizing in an Unfavorable Political Context
In addition to nonpartisan or tailored messaging that appeals to people with divergent political leanings, several other concerns arise in politically hostile environments.
Multiple Issues Complicate Messaging
Particularly when dealing with policies that can be intricate and hard to understand, combining multiple issues poses challenges to messaging and framing a campaign issue.

Power-building assessment

In Nebraska and Montana, we observed moderate increases in power-building and civic engagement. In both states, Medicaid expansion was an issue that had been attempted through the legislature. Nebraska’s win can also be attributed to its unique power-building ecosystem; the relative abundance of local philanthropic dollars—coupled with the strong leadership of one advocacy organization in particular—facilitated the passage of the ballot initiative. Another key insight from Nebraska is that the ballot initiative process can be a useful tool when legislators are out of step with their constituents on an issue. In Montana, two key lessons included the dangers of having a strong opponent—in their case tobacco companies—and the importance of understanding the nuances of how legislation can impact marginalized groups, such as Native communities. It is important to provide resources to local organizers rather than outside consultants who often diminish the possibilities for power-building.

The flat silhouette of Montana and Nebraska

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Outcomes

Metric

Yes/No

Details

Newly activated individuals
NE: Yes
MT: No
Nebraska effectively brought in new advocates such as Amanda Gershon who became a member of the Ballot Committee and Rich Blocker who single-handedly collected 3,000 signatures for the Medicaid expansion initiative. Nebraska Appleseed also grew their base from 1,500 to 5,000 through the Medicaid expansion campaign. In contrast, activating individuals did not seem to be a core part of Montana’s I-185 campaign strategy.
New voters or communities participating in electoral politics
NE: Yes
MT: Somewhat
The Nebraska Civic Engagement Table focused on mobilizing BIPOC-led and BIPOC-focused nonprofits and advocacy organizations to mobilize Black and Latinx voters. The campaign also followed the leadership of the Center for Rural Affairs and volunteers from rural counties to mobilize constituents living in rural areas. In Montana, Western Native Voice reported that every election cycle, they see greater participation from Native voters. However, with I-185, we also saw how the tobacco tax deterred some Native voters from supporting the initiative.
New organizations/programs
No
Respondents did not share information about establishing new organizations or programs for this campaign.
New networks, coalitions or organizing relationships
Yes
In Nebraska, the Nebraska Civic Engagement Table recruited the American Civil Liberties Union (ACLU), the League of Women Voters, Planned Parenthood, the Heartland Workers Center, the Center for Rural Affairs, Civic Nebraska, the Health Center Association of Nebraska, the Institute for Public Leadership, and the Brain Injury Alliance and helped them use Medicaid expansion to mobilize and organize their bases. Nebraska Appleseed also solidified itself as a hub for organizing nonprofits. In Montana, the Hospital Association leveraged its network to carry out the campaign.
New funders
Yes
The Fairness Project and Families USA supported both campaigns financially for the first time.
New audience or increased attention
Yes
Both campaigns caught the attention of national organizations who believed they had the potential to be successful, and Nebraska’s campaign also appealed to more conservative voters, which is a new audience for an issue that is typically thought of as progressive.
New access to decision making
NE: Somewhat
MT: No
In Nebraska, Amanda Gershon who was directly impacted by the health insurance coverage gap became a leader on the campaign and a Ballot Committee member, but overall people's existing relationships to decision-making remained the same. In Montana, advocacy organizations and hospital providers were the major decision-makers which did not create new access.
New positional power for communities that have been traditionally marginalized
No
In Nebraska, elected officials called most of the shots, with Senator Kathy Campbell as the primary decision-maker on the Ballot Committee, Senator Adam Morfeld as the primary liaison with funders, and Nebraska Appleseed and the Nebraska Civic Engagement Table leveraging their existing power. In Montana, the campaign used a pay-to-play model, which gave the majority of the decision-making power to 7 organizations that were able to make significant financial contributions.

Process

Metric

Yes/No

Details

New frameworks or narratives in explaining an issue
NE: Yes
MT: No
Nebraska's campaign adopted the banner of “Insure the Good Life”, a play on their state slogan, which seemed to resonate with voters. In Montana, the campaign’s inability to frame the tobacco tax in a way that worked for Native people and voters on the far left harpooned their success.
New organizing models, strategies or tactics
Somewhat
Nebraska Appleseed rolled out a volunteer-driven distributed organizing model, which helped grow their base during this campaign. In Montana, organizations partnered with national strategists, which was helpful for kicking off the campaign, but too far removed from the ground to build significant power.
Expanding know-how to new groups around ballot initiative or other civic engagement processes
NE: Yes
MT: Somewhat
Nebraska Appleseed held trainings on signature collection and collaborated with the Nebraska Civic Engagement Table to lead storytelling trainings, educate smaller nonprofits, and encourage organizations to see themselves as advocates. In Montana, Western Native Voice described training organizers and developing new leaders, however, civic engagement knowledge-sharing was not something we heard emphasized by other groups.
Community has autonomy and agency throughout the campaign
No
In Nebraska, the campaign focused more on capacity building and leadership development than creating processes that put community members in leadership positions. Montana’s campaign took a more top-down approach that gave larger, well-resourced organizations control over decision-making, which did not facilitate community control.
Community knowledge is respected in the process
Somewhat
The individuals who were activated through Nebraska’s campaign sang Appleseed and OTOC's praises for how respected and valued they felt. This did not necessarily transfer into large-scale community influence, but it does signify that community knowledge and input was valued. In Montana, the campaign did not seem to focus its energy on uplifting community knowledge, but it did defer to culturally specific groups such as Western Native Voice. Montana Women Vote also has an advisory board made up of people who live across the state, which suggests that there is respect for community knowledge.
Campaigns are accountable to community members
No
Respondents did not share information about mechanisms to prioritize community accountability.