Nonprofit Coalition Helps Extend Health Insurance Coverage to 90,000 Nebraskans

“Health care should not be a partisan issue. Whether you are a Republican or Democrat, rich or poor, or live in Omaha or Scottsbluff, you need health care.”
– Molly McCleery, Deputy Director for the Health Care Program, Nebraska Appleseed

The 2018 midterm elections saw record voter turnout and activism, and across the country nonprofit organizations mobilized voters and advocated for and against initiatives that appeared on the ballot. And these efforts led to substantial victories. For example, voters in Missouri and Utah approved the legalization of medical marijuana; in Florida, voters approved Amendment 4 to restore voting rights for ex-felons; and in Austin, voters authorized a record $250 million bond for the purchase of land for affordable housing.

Some of the most important victories for advocates were the ballot measures that voters approved to expand Medicaid in Utah, Nebraska, and Idaho, which will extend health insurance coverage to an estimated 325,000 Americans. While facing an uphill climb in deeply conservative states, nonprofit groups still found success by speaking to residents about their health care needs and challenges, and by relating the ballot measures to the lives of voters’ friends, families, and neighbors.

Note: Federal tax law treats ballot measure advocacy as lobbying, and 501(c)(3) public charities that have made the 501(h) election to measure lobbying must track and report all their lobbying expenditures to the IRS while remaining within IRS lobbying limits. Organizations must track staff time, proportionate overhead, and any direct costs incurred to support or oppose ballot measures. Charities that have not made the 501(h) election to measure lobbying must track all lobbying activities—including the unpaid activities of volunteers—and not just expenditures. For assistance with understanding IRS lobbying rules, contact Bolder Advocacy at advocacy@afj.org or 1-866-NP-LOBBY.

Nebraska Appleseed’s efforts to help pass Nebraska’s Initiative 427—which will insure an estimated 90,000 Nebraskans and sustain 10,000 jobs—is a shining example of how 501(c)(3) nonprofits can work within the parameters of their tax-exempt status to improve people’s lives. Through direct services and policy advocacy, Nebraska Appleseed fights for economic justice, quality health care, child welfare, democracy, and to support immigrant communities in Nebraska. Working with the Insure the Good Life Coalition, Nebraska Appleseed and its partners leveraged their expertise and statewide connections to persuade and mobilize voters to vote for Initiative 427.

Here is a sampling of their activities.

Volunteer Coordination

Nebraska Appleseed organized 300 volunteers to gather almost 15% of the 135,000 signatures that were submitted for the measure to appear on the ballot statewide. Once the measure was on the ballot as Initiative 427, volunteers then went door-to-door and called people who signed the petition as a “second touch” to encourage them to vote for the measure in November. The organization’s presence and direct services across the state, along with their initial conversations to gather signatures, helped make the get-out-the-vote outreach more effective.

Grassroots Organizing

Through conversations with people door-to-door and gathering stories for letters to the editor and op-eds, Nebraska Appleseed was able to highlight the human impact of the “coverage gap.” People who do not qualify for Medicaid but cannot afford private health insurance, and whose incomes are not high enough to qualify for tax credits under the Affordable Care Act, are in what’s colloquially known as a “coverage gap.” Nebraska Appleseed and their partners’ focus on the challenges uninsured people in the coverage gap face was crucial to their efforts to pass Initiative 427.

Nebraska Appleseed organized meet-ups for people in the coverage gap for them to exchange stories, share a meal, and create a sense of a community and a network. The organization also prioritized leadership development for people in the coverage gap, so the people directly impacted by the state’s refusal to expand Medicaid would have a central role in both the ballot measure campaign and in the ongoing fight for health justice.

Public Education

With a track record of expertise on health care access and the Medicaid program in Nebraska, Nebraska Appleseed was well positioned to educate the public on the ballot measure. During the campaign, they presented at voter forums to receive community feedback and developed straightforward and informative factsheets on Initiative 427. When communicating one-on-one with voters, Nebraska Appleseed corrected misconceptions about the Medicaid program and explained how Medicaid expansion could directly benefit voters and their loved ones. The organization found that when people could identify specific people in their lives that would benefit from Medicaid expansion, they were more likely to support Initiative 427 than if the organization referred to political parties or political ideology. As one organizer in Idaho succinctly put it, “I respect those who want (limited) government. But I want to save lives. That’s my ideology.”

The Insure the Good Life coalition also pursued a variety of paid media strategies to inform voters about the ballot measure by paying for advertisements on television, radio spots, and direct mailers on the benefits of Medicaid expansion. Nebraska Appleseed was often content to let partners—some of whom were 501(c)(4)s or unions—pursue paid media strategies because of their unique expertise and capabilities.

Technical Assistance

As a subject-matter expert, Nebraska Appleseed was an important resource for reporters and legislators who were considering endorsing the measure or were seeking to better understand its potential impacts. And because 501(c)(3)s are required by federal law to be nonpartisan—they can’t support or oppose candidates from office—state legislators from both sides of the aisle felt comfortable approaching Nebraska Appleseed for data, research, and information on the coverage gap in Nebraska.

Initiative 427 passed because of the countless efforts of nonprofits, residents, volunteers, and other community groups across Nebraska and its 93 counties. Nebraska Appleseed’s efforts are just one example of how a 501(c)(3) public charity can engage in ballot measure advocacy to make a real difference in people’s lives.

But the work isn’t over. As the Governor and legislature and social services department work through how to implement Medicaid expansion, there may be significant administrative advocacy—which is not considered lobbying under IRS rules—that is required. The fight continues, but the arc of justice bends because of nonprofits, and their staff, volunteers, and supporters.