Maine will become the 33rd state to expand Medicaid under the Affordable Care Act, extending coverage to as many as 89,000 low-income residents.

The Associated Press and NBC News projected the victory late Tuesday.

Maine is the first state to expand Medicaid during the Trump administration, and also the first to do so via a ballot initiative rather than legislation. This offers a possible playbook for health care advocates in other states looking to extend coverage but stymied by political opposition.

Medicaid expansion actually has a fair amount of bipartisan support in Maine. Earlier this year, I wrote about a Republican state legislator named Tom Saviello who has repeatedly introduced bills to expand the Medicaid program.

“The people I represent need this,” he told me. “It’s as simple as that.”

The legislature had actually passed five separate bills to expand Medicaid prior to the ballot initiative. But Maine Gov. Paul LePage, a Republican, has vetoed all of them. Unsurprisingly, LePage had also been a vocal opponent of the Tuesday ballot initiative. Here's what he said in a radio address last week:

This Medicaid expansion is not for children or the elderly. They are already covered by Medicaid. This Medicaid expansion would give “free” health care to able-bodied adults who can work and contribute to their own health insurance costs. I’ve said it before: “Free” is very expensive to somebody. This time, it will cost Maine taxpayers up to $500 million in the next five years. Maine learned this the hard way when it expanded Medicaid in 2002.

LePage was citing numbers from Maine Heritage Policy Center, a conservative think tank in the state that has estimated that “when fully implemented,” the state will need to spend $54 million annually on Medicaid expansion — but will receive $525 million in federal funds in return.

The federal government pays the vast majority of Medicaid expansion costs for all states that participate in the program. Washington would pay 94 percent of the Maine Medicaid expansion costs in 2018, with the match rate eventually falling to 90 percent by 2021.

Maine will join 33 other states that have so far expanded Medicaid

Nearly three dozen states have opted in to the Affordable Care Act provision that allows states to expand the public Medicaid program to low-income residents.

Estimates vary on how many people will gain coverage because of Maine’s decision to expand. The nonprofit Urban Institute estimates that 32,000 Maine residents live in the “coverage gap” (too poor to qualify for private insurance subsidies but too rich to qualify for Medicaid), while organizations in Maine peg the numbers significantly higher. Mainers for Health Care, which has advocated for the Medicaid expansion, estimates 70,000 will gain coverage, whereas an independent state agency puts the number at 89,000.

A Medicaid playbook for other states?

Maine turned to a ballot initiative after its governor repeatedly vetoed bills to expand Medicaid. Now that the state has been successful, others are eying the same model.

“We would love to put Medicaid on the ballot in as many states as possible,” says Jonathan Schleifer, executive director of the Fairness Project, a national nonprofit that has supported the Maine initiative.

Schleifer identified Utah and Idaho as two states where there are already initial conversations about putting a Medicaid expansion question on the state ballot in 2018.

Another target could be Kansas. Like Maine, its legislature has passed Medicaid expansion bills only to have them vetoed by Gov. Sam Brownback, a steadfast opponent of the Affordable Care Act.

“A ballot initiative allows you to go around the political process and go straight to the people,” says Schleifer.