As the Trump administration and Republicans in Congress look toscale back Medicaid, many voters and state lawmakers across the countryare moving to make it bigger.

On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under theAffordable Care Act. Advocates are looking to follow suit withballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after theLegislature thwarted Gov. Terry McAuliffe’s attempt to expandMedicaid. Virginia voters elected Democrat Ralph Northam to succeedMcAuliffe as governor in January, and Democrats made inroads in thestate Legislature, too.

An exit poll of Virginia voters on Election Day found that 39percent of them rankedhealth care as their No. 1 issue. More than three-quartersof the Virginians in this group voted for Democrats.

A study fromthe Urban Institute may shed light on why Medicaid eligibilityremains a pressing problem: medical debt. While personal debtsrelated to health care are on the decline overall, they remain farhigher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can beall-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City,Mo. She has a long history of health problems, including a blooddisorder, depression and a painful misalignment of the hip jointcalled hip dysplasia.

She’s managed to find some peace living in a small cabin in thewoods. She keeps chickens, raises rabbits and has a garden. Herlong-term goal is to live off her land by selling what she raisesat farmers markets.

Her health has made it hard to keep a job and obtain theinsurance that typically comes with it. And Missouri’s stringentMedicaid requirements — which exclude nondisabled adults withoutchildren — have kept her from getting publicassistance.

Since graduating from college more than 20 years ago, Wilson hasmostly had to pay out-of-pocket for medical care, and that’s lefther with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and Ihave to start all over again,” Wilson said.

Right now her medical debt stands at about $3,000, which shepays down by $50 a month. She desperately needs a hip replacement,but she canceled the surgery because, even with a deeply discountedrate from a nearby hospital, she couldn’t afford it.

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This story is part of a partnership thatincludes KCUR, NPR andKaiser Health News. KHN, a nonprofit health newsroomwhose stories appear in news outlets nationwide, is an editoriallyindependent part of the Kaiser Family Foundation.

“Approximately $11,000 is what would come out of my pocket topay for the hip. That’s my entire pretax wage from last year,”Wilson said. “So it’s kind of on hold, but I don’t know if I cansurvive the year without going ahead and trying to get itdone.”

For many people like Wilson, medical debt can be nearly asproblematic as an illness. In 2015, 30.6percent of Missouri adults ages 18 to 64 had past-duemedical debt, the seventh-highest rate in the country. Kansas, at27 percent, had the 15th-highest rate. In Maine, which voted toexpand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golberstein of theUniversity of Minnesota studied financial data from 2012 to 2015for people who would be eligible for Medicaid where it wasexpanded.

They found that in states that didn’t expand, the percentage oflow-income, nonelderly adults with unpaid medical bills droppedfrom 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACAcontributed to a 7-percentage-point reduction,” Sojourner says.“Where they did expand Medicaid, it fell by almost twice asmuch.”

Those states saw an average drop of 13 percentage points, from43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fellby 4 percentage points to 27 percent. In Missouri, the rate dropped4 points to 31 percent, according to the Urban Institute. In Maine,it dropped only 1.4 percentage points from 2012 to 2015.

Medicaid, as opposed to private insurance, is the key, said theUrban Institute’s Kyle Caswell,because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, they aren’t on thehook for big out-of-pocket costs in the same way someone withprivate insurance might be.

“We would certainly expect their risk to out-of-pocket expensesto be much lower, and ultimately the risk of unpaid bills toultimately be also lower,” Caswell said.

But Medicaid’s debt-reducing advantages over private insurancecould disappear under the leadership of the Trumpadministration.

Shortly after Seema Verma was confirmed as the administrator forthe Centers for Medicare & Medicaid Services, she and TomPrice, then head of the Department of Health and Human Services,sent aletter to the governors outlining their plans forMedicaid.

The letter encouraged states to consider measures that wouldmake their Medicaid programs operate more like commercial healthinsurance, including introducing premiums and copayments foremergency room visits.

Verma said that by giving recipients more “skin in the game,”they will take more responsibility for the cost of care and savethe program money.

Republican proposals in Congress to repeal and replace theAffordable Care Act would have eliminated or limited Medicaidexpansion. And that would have affected the last few years’downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would havethe reverse effect of what we’re seeing in our paper,” Caswellsaid. “Reduced access to Medicaid would likely increase exposure tomedical out-of-pocket spending and ultimately unpaid medicalbills.”

As Geneva Wilson tends to her chickens, she said, she tries notto think too much about her medical debt or how she’ll pay for thathip replacement.

“It’s going to the point where, if I were to go shopping atWalmart, I would have to get one of the carts you drive because Ican’t manage,” she said.

Wilson has already sold her jewelry, some furniture and a woodstove to pay down her debts. Now there’s not much left to sellexcept her cabin and her land.

“Probably the homestead and garden that I want, that I’ve beenwanting and trying to work for, I don’t think they are a viabledream either,” Wilson said. “It’s hard losing your dreams.”

This story is part of a partnership that includes KCUR, NPR and Kaiser HealthNews. KHN, a nonprofit health newsroom whose storiesappear in news outlets nationwide, is an editorially independentpart of the Kaiser Family Foundation.