Voters in four states will decide Nov. 6 whether to expand Medicaid under the Affordable Care Act, with the initiatives spurring some $20 million in political spending and testing the public’s appetite for expansions in states where the ACA remains unpopular.

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Supporters of the initiatives cast tobacco’s opposition as a badge of honor.

“This is like David versus Goliath—if Goliath also gave people cancer,” said Jonathan Schleifer, executive director of The Fairness Project, which backs the ballot measures.

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