2018 is shaping up to be a watershed year for Obamacare’s Medicaid expansion.

Virginia’s legislature signed onto the expansion of coverage for low-income Americans last week. Three additional states are looking at doing the same through ballot initiatives in November, which are starting to gain steam.

If all four states join Medicaid expansion in 2018, it will be the highest number since the option first became available when Obamacare launched — and would expand coverage to more than a half-million low-income Americans, many living in deep red states.

”This is potentially more states shifting since the initial launch in 2014, which is significant,” says Matthew Buettgens, a senior fellow at the Urban Institute who studies the effects of Medicaid expansion.

In a way, this is what experts have long predicted for Medicaid expansion: that once President Barack Obama left office the program would become less polarizing, and red states would be more open to participating in the program.

States also seem more confident pursuing Medicaid expansion now than they would have a year ago, when Republican repeal plans could have ended the program entirely or significantly cut its funding.

”Back in 2016, there were some efforts to expand Medicaid, but everyone pulled back in 2017 to see whether or not the law would still be standing,” Buettgens says. “It seems that states now feel confident counting on the broad federal policy staying roughly the same in the near-term to start moving forward.”

We know that Virginia now plans to expand Medicaid, after four Republican senators there crossed party lines to vote with Democrats in favor of the health coverage program. The vote came after Democratic governors — first Terry McAuliffe, now Ralph Northam — have spent years trying to woo a Republican-controlled legislature into supporting the program. This year, the parties were able to strike a deal by adding a work requirement into the expansion that brought a handful of conservative legislators on board.

The next big development to watch will be Medicaid ballot initiatives in four red states: Utah, Idaho, Nebraska, and Montana. (Montana currently participates in Medicaid expansion, but the program is set to end in 2019, hence the ballot effort to extend it.)

The Utah lieutenant governor has certified that the ballot initiative there has gathered enough signatures to get a vote in November. Organizers in Idaho believe they’ve turned in enough votes to also make a ballot, but the state has until July 5 to certify the results. In Nebraska and Montana organizers are still gathering signatures.

”Virginia was incredibly exciting, but we don’t really see other states where the legislature is going to find inspiration and move through the traditional process,” says Jonathan Schleifer, executive director of the Fairness Project, a national group assisting state-level Medicaid ballot initiative efforts. “We’re seeing there is tremendous support for ballot initiatives as another route.”

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Maine was the first state to expand Medicaid via ballot initiative; it did so last year in an off-cycle vote. In a lot of ways, Maine’s experience shows the promise and peril of using this particular route.

On the one hand, the Maine ballot initiative passed overwhelmingly, by a 17 percentage point margin. It was a state that made clear that this type of ballot can win at the polls.

But Maine’s Medicaid expansion still hasn’t taken effect, largely because Republican Gov. Paul LePage refuses to implement the program. He currently faces a lawsuit over the issue.

So even while Maine’s Medicaid ballot initiative passed easily, it still hasn’t translated into low-income Maine residents gaining coverage. Most observers expect this will likely be resolved later this year, when LePage is term-limited out of office and a new governor takes over.

Schleifer, for his part, is optimistic that other states won’t run into this outcome. For starters, two state ballot initiatives (Utah and Montana) include specific funding sources to pay for the state’s share of Medicaid expansion — much of LePage’s obstruction centers around not finding the money for Maine to kick in its 10 percent funding share of the program.

As for Idaho and Nebraska, what happens if those efforts do come to a vote?

Obstruction, Schleifer says, “is always a concern. It’s why we’re talking to legislators now, on both sides, asking them to respect the will of the people. It also speaks to the imperative to win big. The larger the support fo the base, the harder it is for political partisans to stand in the way.”

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