Obamacare’s Medicaid expansion is set to grow by about a half-million after voters in three deeply red states rebuked Republican leaders to approve ballot measures joining the program and Democrats took back governors' mansions Tuesday night.

The elections will usher in the program’s largest growth since Obamacare’s early days, after Republican leaders in those states resisted the optional program for years. Democratic victories in Kansas, Maine and Wisconsin gubernatorial races could soon put those states in the expansion column, and voters in Idaho, Nebraska and Utah easily approved initiatives adopting the program.


Obamacare supporters said the victories marked a strong reprimand of Republican efforts to roll back the Affordable Care Act. The Democrats’ House victory also represents a firewall against Republican efforts to repeal Obamacare or cap Medicaid spending for at least the next two years.

“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong,” said Jonathan Schleifer, executive director of the Fairness Project, which bankrolled the Medicaid ballot initiatives. “Expanding access to health care isn’t a blue-state value or a red-state value; it’s an American value.”

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On an election night with mixed results for both parties, Medicaid expansion was an unambiguous win. Still, the two biggest prizes for expansion supporters — Florida and Texas — will remain firm holdouts after Tuesday night.

Medicaid expansion under the ACA has largely driven the decline in the nation’s uninsured rate since the program began in 2014, with more people signing up than expected. But few states have joined after an initial surge, as Republicans vowed to scrap the health care law and GOP legislatures worried enrollment spikes would wreck their budgets, even though the federal government shoulders the vast majority of the program’s cost. The Trump administration has also sought to curtail enrollment in the program, approving first-ever work requirements in some states that are facing legal challenges.


Tuesday’s election will likely bring Obamcare’s Medicaid expansion, which nearly two-thirds of states have adopted, to the most conservative parts of the country. It could soon come to Kansas, where Democratic Gov.-elect Laura Kelly defeated Republican Kris Kobach, a close ally of President Donald Trump. Kansas lawmakers approved Medicaid expansion last year, but then-Gov. Sam Brownback vetoed it.

In Wisconsin, Democrat Tony Evers narrowly defeated Gov. Scott Walker after campaigning on Medicaid expansion. He’s vowed to use “legal means” if necessary to overcome resistance from Republican legislators, who said they would oppose any effort to expand the program.

“We have to get those resources, and we’re going to get it,” Evers told reporters at a campaign really in October. “But I do think we can work together.”

In Maine, Democrat Janet Mills’ victory over an anti-Obamacare Republican will end Gov. Paul LePage’s blockade of the program. LePage, the term-limited tea party firebrand, vetoed numerous expansion bills in recent years and is still fighting in court a 2017 ballot initiative ordering the state to expand Medicaid.


The Maine ballot measure, which was the first of its kind, helped inspire similar efforts among frustrated advocates in other Republican-controlled holdout states. Idaho, Nebraska and Utah voters easily approved Medicaid expansion on Tuesday night, but it remains to be seen whether Republican officials in those states will stand in the way.

To implement Medicaid expansion, lawmakers in Nebraska and Idaho will have to address how to finance their states' share of the program's costs. States cover a small but gradually increasing portion of costs, which eventually settle at 10 percent. Utah's ballot measure included a small boost in the state's sales tax to help pay for Medicaid expansion.

States with large numbers of uninsured adults are likely to remain expansion holdouts after Republicans retained control of governorships. A narrow GOP victory in Florida and a likely win in Georgia will prevent more than 1 million from gaining Medicaid coverage. In Texas, the nexus of anti-Obamacare fervor, about 1.2 million poor adults aren’t eligible for expanded Medicaid because of Republican opposition.

In Montana, which expanded Medicaid in 2015, voters apparently rejected a ballot measure that would have permanently funded the program beyond its June 2019 sunset date. Republican state lawmakers have said they want to continue the program with new work requirements. The ballot results have not been certified as of Wednesday morning.

