The Virginia state Senate voted Wednesday to expand Medicaid under the Affordable Care Act, with four Republicans crossing party lines to join all Senate Democrats in backing the move. The House of Delegates, which already passed a version of Medicaid expansion, will need to vote again to make expansion a reality, but the odds now seem overwhelming that Virginia will become the 33rd state to expand Medicaid (Washington, DC, has also expanded).

That’s big news for about 400,000 poor and near-poor Virginians who will gain access to affordable health insurance, and a big deal to the state’s health care providers, who’ll get an injection of clients and money — an important topic for residents of rural areas writ large since expansion helps ensure that hospitals can stay in business, which helps even people who aren’t directly assisted by Medicaid expansion.

In political terms, expansion is a huge victory for the state’s Democratic governor, Ralph Northam, who made expansion a key campaign priority, and for the many Democrats who swept into the state legislature last November and came extraordinarily close to securing a majority in the House of Delegates.

The road to expansion

The big break came in April, when Republican state Sen. Frank Wagner announced he would support Medicaid expansion (with some conditions), which gave the proposal enough votes to pass as part of the state’s budget. Republicans control the Virginia Senate by a narrow 21-19 margin, and Wagner was the second of two GOP senators needed to support expansion.

Even since Northam won the governor’s mansion in November and down-ballot Democrats narrowed the GOP’s House majority dramatically, Medicaid expansion became the top item on the state’s agenda. The narrowly GOP-held House passed a version of the proposal in February, but the Senate took months to agree.

Virginia will be the first state to officially accept Medicaid expansion under President Donald Trump, and the 33rd overall. To date, 18 mostly Republican-led states have refused to expand Medicaid under Obamacare, leaving an estimated 4 million people without health coverage.

Ballot initiatives are the next Medicaid fight

No other state legislatures appear to be close to expanding Medicaid, but advocates are hoping that ballot initiatives can deliver success in three more red states this fall.

Utah, Idaho, and Nebraska seem poised to hold referendums on the subject, building on a successful precedent from Maine last November. Medicaid expansion is generally very popular, even among voters who are fairly loyal to the Republican Party, but there is extreme pressure in elite GOP circles to avoid embracing it. Consequently, ballot initiatives can be a way of bypassing the party cartel process and allowing voters with conservative views on abortion, gun regulation, environmentalism, etc. to get their progressive health care policy without turning against their preferred political party.

In numerical terms, however, by far the largest number of potential beneficiaries of Medicaid expansion live in Texas and Florida. Neither of those states has yet to see a serious ballot campaign, and Democrats’ odds of making adequate electoral gains this fall to put it on the agenda in Austin are essentially nil.

Florida, however, has an open race for governor this fall, and while it’s been a long time since a Democrat was elected governor there, it’s a swing state in presidential races and a plausible pickup opportunity. A pro-Medicaid governor along wouldn’t necessarily make expansion happen, but it certainly doesn’t hurt, and the prospect of expansion in the state is one of the most consequential aspects of the 2018 midterms.