Standing outside the gun shop she co-owns, next to her SUV sporting "NRA" on the license plate, Christy Perry pledges full support for President Donald Trump. "He is doing a good job," said Perry, a four-term Republican member of the Idaho legislature who has voted for a litany of conservative causes, including weakening labor unions, restricting abortion and boosting charter schools.

With those credentials, Perry hopes for another big win on Election Day one that puts her at odds with Trump and GOP orthodoxy. She is helping lead the drive to persuade state voters to expand Medicaid — a central tenet of the Affordable Care Act, the 2010 law embraced by Democrats and derided by many Republicans.

Perry has been pushing for Medicaid expansion the past several years in the state legislature, but top House leaders thwarted those efforts. Now a ballot initiative, Proposition 2, puts the matter before Idaho voters.

Perry said Medicaid coverage is desperately needed by people struggling in low-wage jobs and the economics make sense for the state given the federal government will pay a 90% share. An expansion will reduce or eliminate the need for other Idaho-funded programs to help the uninsured, she said.

If the push is successful on Nov. 6, about 62,000 Idaho adults would be added to the state-federal health insurance program that covers 73 million low-income Americans. It would be a major advance for Obamacare into one of the most conservative parts of the country.

Expanded Medicaid

Idaho is one of the remaining 17 GOP-controlled states where lawmakers have steadfastly resisted expanding Medicaid. But voters in Idaho, Nebraska, and Utah will decide next month whether to buck their political leaders and go forward with the expansion.

The issue is also on the ballot in Montana, which expanded Medicaid in 2016. There, residents will decide whether to continue it past 2019. Of those states, Idaho is arguably the least politically hospitable for Medicaid expansion. Trump carried Idaho by the largest margin — nearly 32% points.

Last year, Maine became the first state to approve expanding Medicaid via a ballot referendum, although the GOP governor has stalled implementation. Unlike Maine, where political power has been split between Democrats and Republicans in recent years, Idaho, Utah, and Nebraska are solidly GOP territory.

Trump and Republican congressional leaders have vowed to repeal the health law, which made expansion possible by providing the bulk of the funding for those who qualify for new coverage.

Perry, 50, does not see a problem getting Trump voters to back the expansion. She said that the Republican failure to repeal the law last year opened the door for conservative states to go forward.

"I think people here listen to that and it now falls to states to go ahead" with expansion, she said. Supporters of the referendum were successful at garnering 70,000 signatures to put the vote on the ballot, but they face a steep challenge educating the electorate about the complexities of Medicaid financing.