It wasn't all that long ago that Grant Burningham was homeless and sleeping in a tent in the woods.
"That's hard for me to talk about because I thought I had reached the end," he says.
Burningham, a former financial adviser from Bountiful, Utah, developed serious medical problems 17 years ago. Back in 2001, Burningham offered to donate his stem cells to his sister for a transplant. It required multiple procedures, and each time Burningham was given high doses of a medication to boost his immune system.
"And then I got really sick," he says.
He believes it was a reaction to the drug that ended up causing a constellation of strange symptoms.
"I literally got what might even be termed the boils of Job. I have scars all over my body now," he says. "And then I got some really strange severe headaches and fatigue, and that was associated with the blood pressure that got remarkably high."
He lost his job, his health insurance and eventually he lost his home. Now he has a place to live but still can't get the care — or even a diagnosis — that might allow him to get back on his feet.
That could all change. On Election Day, Utah residents will be going to the polls to vote on whether the state will join 33 others and Washington, D.C., in expanding Medicaid coverage to a lot more low-income adults. Democrat and Republican states have expanded.
Nebraska and Idaho also have the Medicaid question on ballots in their states. Idaho Gov. Butch Otter, a Republican, endorsed the expansion initiative Tuesday. And in Montana, voters will decide whether to approve a tobacco tax to continue that state's Medicaid expansion or let it roll back next year.
Before the Affordable Care Act, Medicaid, the government health insurance for the poor and disabled, was reserved mainly for pregnant women, poor children, low-income seniors and people with disabilities.
With the ACA came the requirement for states to expand access to Medicaid to childless adults whose incomes are less than 138 percent of the federal poverty level, which is $12,140 for individuals. As part of the deal, the federal government foots most of the bill, now covering 90 percent of the health care costs of the expansion patients. A later court case made the expansion, in essence, optional for states.
Utah has come close to expanding Medicaid in the past. In 2014, the governor pushed for a modified expansion. But that died in the state's house. Earlier this year, lawmakers agreed to a limited expansion that requires people on Medicaid to work or volunteer to qualify for benefits. That measure has yet to be approved by the federal government.
Burningham has been there through it all. He testified before the Utah Legislature several times over the years. This time around, he collected some of the 130,000 signature required to put the question directly to voters. Some he collected from the staffers he got to know in the capital.
"I also sat, very humbly and very quietly, and maybe got two or three signatures a week over a six-week period at a food bank up in Ogden, Utah. That's where I had spent most of my homeless time, was in Ogden." Burningham says.
The campaign to get Medicaid expansion onto the ballot in Utah and the three other states has been led by The Fairness Project, a nonprofit advocacy group that pushed for ballot measures on issues where lawmakers seem out of sync with citizens. The group is funded by the SEIU United Healthcare Workers West, a California health care workers union.
"The real gap on health care is not between Democrats and Republicans, it's between politicians and everyone else," says Jonathan Schleifer, executive director of the Fairness Project. "Politicians have made health care a divisive political issue. But when you ask most Americans whether they want more health care or less, they want more health care."
The Fairness Project and Utah Decides, a state-level group campaigning in favor of expansions, argue that expanding Medicaid has economic benefits as well as health benefits. Schleifer points to a study in the October 2017 issue of the journal Health Affairs that shows an 11 percent decline in payday loans in California after that state expanded Medicaid benefits.
RyLee Curtis, campaign manager for Utah Decides, says the goal is to ensure financial and health stability for her neighbors.
"These are hardworking Utahans," she says of the people who would qualify for Medicaid under the proposed expansion. "About a third of them are parents with children in the home and oftentimes they're working one or more jobs and they're unable to afford health care coverage."
Religious leaders in Utah are also calling for expansion. Earlier this month, several of them held a news conference calling on voters to vote for expansion.
"We as state leaders believe in the dignity and sanctity of life," said Bishop Oscar Solis of the Catholic Diocese of Salt Lake City. " And to promote the dignity and the sanctity of life. We need to provide basic needs for people and that includes healthcare."
The Church of Jesus Christ of Latter-day Saints hasn't taken an official position on the Utah ballot question, though some individual leaders have endorsed it.
But expansion has vocal opponents. David Barnes of Americans for Prosperity, a conservative advocacy group funded by billionaire industrialists Charles and David Koch which is campaigning against the measure, says states like Utah shouldn't risk expanding Medicaid because groups like his are still trying to repeal the Affordable Care Act.
"If states go ahead and expand Medicaid assuming there's a big federal pot of money that's going to be available to them to do this, and then find out after the fact that they've expanded coverage but then can't pay for it, that's going to be a problem for them," says Barnes.
He says Medicaid expansion is flawed because federal funding is more generous for the expansion population than for the children and disabled people that Medicaid was originally intended to help.
In Utah, Americans for Prosperity has about 50 people on the ground working to defeat the measure. They've hosted pizza parties and called more than 23,000 voters.
The Utah plan, as laid out on the ballot, is to fund the Medicaid expansion by adding 0.15 percent to the state's sales tax, which works out to about 1.5 cents for every $10 residents spend on nonfood purchases.
A poll conducted in early October by The Salt Lake Tribune and the Hinckley Institute shows that 59 percent of Utah voters favor the expansion, which could bring health insurance to 150,000 people.
Burningham is optimistic that he'll be one of them: "I think it's going to pass. I really do."