The races for governor this November in Kentucky, Mississippi, Louisiana, and Virginia haven’t attracted nearly as much attention as next spring’s presidential primaries, but they are hugely important to hundreds of thousands of voters without access to health care.

Leaders in the four states have rejected or put tough restrictions on extremely generous federal matching funds allocated under the Affordable Care Act (ACA) to extend their Medicaid programs to cover families earning up to 133 percent of the federal poverty level. Next week, depending on who becomes governor in these states, that could change or solidify.

The stakes are very real. A recent study from four researchers — University of Michigan economist Sarah Miller; University of California, Los Angeles public health scholar Laura Wherry; National Institutes of Health’s Sean Altekruse; and Norman Johnson with the US Census Bureau — estimates that failure to expand Medicaid leads to about 15,600 extra deaths per year just among people ages 55-64.

After the passage of the ACA, Democratic states mostly took the expansion money, adding over 7 million more Americans to insurance rolls in recent years. GOP-run states mostly didn’t, though a handful of GOP governors have accepted expansion funding but done so under waiver systems that let them impose heavy work requirements and other administrative burdens on recipients.

Originally, the ACA stipulated that states that failed to expand Medicaid would lose their existing federal funding, which would have made expansion all but inevitable. But a 6-3 Supreme Court ruling in which the five conservative justices were joined by Elena Kagan struck down that punitive aspect of ACA expansion as unconstitutional.

The decision set off a years-long series of state-by-state battles with very real stakes. Next week several of those fights are coming to a head.

Kentucky and Louisiana: Work requirements on the line

In Kentucky and Louisiana, Republican candidates want to keep or set new work requirements for Medicaid recipients while Democrats want to lift or prevent them.

Kentucky expanded Medicaid at the first possible opportunity back under then-Gov. Steve Beshear, a Democrat. His successor, Matt Bevin, got a waiver from the Trump administration to impose stringent work requirements that are currently being held up in court. A comprehensive study in the New England Journal of Medicine of a similar program in Arkansas found that work requirements reduce enrollment and raise the uninsured rate without doing anything to increase employment.

It seems likely that if Bevin is reelected he will prevail in what’s an increasingly conservative-dominated federal judiciary.

Bevin’s opponent is Beshear’s son, Andy, who is also the state’s attorney general. Andy Beshear opposes Bevin’s changes to Medicaid and could recapitulate his father’s success in driving the Kentucky uninsurance rate down to record lows.

Louisiana, meanwhile, is essentially facing the same choice Kentucky faced back when Bevin was first elected. The state’s incumbent governor, moderate Democrat John Bel Edwards, won in 2015 and expanded Medicaid, leading to a huge increase in the number of Louisiana residents able to access basic health care services. He’s made Medicaid one of the centerpieces of his re-election campaign.

Louisiana Republicans — with some success — are trying to downplay the issue. But while Edwards’s opponent, businessman Eddie Rispone, says he wants to “freeze” enrollment until alleged fraud can be investigated and is also interested in Kentucky-style work requirements.

Mississippi: A Democrat could expand Medicaid

A Democrat winning a statewide race in Mississippi sounds unlikely, but the party has a strong candidate in longtime Attorney General Jim Hood, and the (scant) polling has shown a tight race between him and Lt. Gov. Tate Reeves.

Mississippi has one of the lowest health insurance rates in the country (45th out of 50) and the lowest median household income.

Consequently, the upside to Medicaid expansion — which would both cover many people and provide a large injection of federal money into the state economy — is large, and Hood is pushing strongly for it.

Beyond the specific consequences for Mississippi, the mere fact that it’s such a long-shot race would send a clear signal about the potency of the Medicaid expansion as an issue.

Virginia: Control over the state legislature

Virginia has acted as mostly a blue state in recent years, voting for Barack Obama twice and then Hillary Clinton, sending two Democratic senators to DC, and electing two Democratic governors in a row. But in part because of aggressive gerrymandering, the state legislature has remained in GOP hands for years.

Former Democratic Gov. Terry McAuliffe tried repeatedly to expand Medicaid but was blocked by the legislature. His successor, Ralph Northam, got it done after Democrats picked up a few seats in 2017, but he had to make some compromises limiting eligibility.

Republicans currently hold narrow two-seat advantages in both the state Senate and the House of Delegates, but Northam carried strong majorities in districts for both houses during his 2017 election. That, plus strong fundraising and polling that seems to show Trump has become even less popular in Virginia over time, makes Democrats very optimistic about the ability to flip both chambers despite the cloud of scandal hanging over their statewide elected officials.

The implications of a possible flip in control are wide-ranging, especially that they include control over the redistricting process after the 2020 census, but, of course, extend to health care. A Democratic state legislature would likely lift those restrictions on eligibility and could even join other Democratic-run states in experimenting with larger expansions of government-provided health insurance.