Second: The program will be expanded next year in three GOP-led states — and possibly two more — that up until now had declined to extend Medicaid coverage to Americans earning up to 138 percent of the federal poverty level, as envisioned under the ACA.

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Voters in Idaho, Utah and Nebraska approved ballot initiatives for Medicaid expansion, making a combined 363,000 more people eligible for the program next year. And Democrats won gubernatorial races in Wisconsin and Kansas, two other Republican-led states that had resisted expansion but now may be more open to it.

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We should mention another state, too. In Maine, the very first state to approve Medicaid expansion via a ballot question in 2017, Gov.-elect Janet Mills (D) says carrying it out will be a top priority. Her predecessor, Paul LePage (R), had held up expansion in court, saying it would cost the state too much money.

“Citizen power propelled the biggest expansion of Medicaid in heavily Republican states since the early years of the Affordable Care Act, with hundreds of thousands of poor and vulnerable residents standing to gain health coverage as a result of Tuesday’s elections,” our Washington Post colleague Amy Goldstein wrote.

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Let’s add it all up. With the addition of Idaho, Utah and Nebraska, 36 states and the District are on board with expanded Medicaid. That number could very well climb to 38 states if Kansas and Wisconsin eventually follow suit. All told, about half a million more people could join the massive federal-state health insurance program for the low-income and disabled that covers more than 1 in 5 Americans.

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To Democrats and supporters of the ACA, that’s a huge victory, given the central role Medicaid has played in the Obamacare wars:

Jesse Lehrich, communications director of Organizing for Action:

Many Republican governors spurned the extra federal expansion dollars provided under the ACA, citing opposition to the health-care law and arguing it would still cost their states too much money. But it appears — at least in the ballot initiative states — that voters didn’t quite agree with their political leaders.

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“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong,” Jonathan Schleifer, executive director of the nonprofit Fairness Project, a group that worked to get the initiatives passed, told reporters Wednesday. “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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Republicans ran straight into that reality when they tried to repeal and replace Obamacare last year, struggling to gin up public support for their House and Senate health-care bills, which would have pared back Medicaid spending. While Republicans like to envision a society in which people don’t need to rely on the government for help, it’s hard to sell that idea to people who stand to lose such benefits.

Now that even more states are jumping onto the Medicaid expansion bandwagon, the ACA will be even more entrenched — further darkening Republicans’ chances of ever repealing it. Just 14 states, primarily in the South and Midwest, are holdouts. An estimated 2.2 million people in those states are missing out on Medicaid coverage as a result, according to estimates by the Kaiser Family Foundation.

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The next step for Idaho, Nebraska and Utah is to submit a state plan amendment to the Centers for Medicare and Medicaid Services. Once CMS approves these SPAs, typically within a few weeks or months, states can move forward with expanding enrollment.

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Utah officials are aiming to have the expansion program ready by April 1, the deadline laid out in the ballot initiative itself. It’s a big job, considering the state is projected to increase its total Medicaid enrollment by 50 percent. But Utah Medicaid Director Nathan Checketts told me his staff started setting the wheels in motion even before Tuesday’s election, when they saw polling on the initiative.

“We saw the polling numbers were high, that it looked like it would pass,” Checketts said. “So we’ve been working behind the scenes to be considering what types of system changes might be necessary. We think we can hit those targets, but there is a lot of lead time.”

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AHH, OOF and OUCH

AHH: Are Republicans ready to help improve the ACA, eight years after it was passed and shortly after an election in which their efforts to repeal it was a central theme? Senate Majority Leader Mitch McConnell (R-Ky.) acknowledged during a post-election news conference that Republicans have lost their chances of repealing the ACA now that Democrats have successfully recaptured the House -- and suggested bipartisan solutions.

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“I think it’s pretty obvious a Democratic House is not going to be interested in that,” he said about repealing the ACA."There are serious problems with Obamacare, serious problems that need to get fixed. ... I think we are going to have to address that, now, on a bipartisan basis.”

“Beyond the practical barriers, Republicans also offered a political imperative for abandoning the nearly decade-old fight: the defeats they suffered to Democrats who ran hard against their efforts to roll back the law,” our Post colleague Sean Sullivan writes. “The GOP faced a moment of reckoning on an issue that helped them ascend to power in 2010 and which some now believe has been part of their downfall. They must chart a path forward amid disagreements within the party about the best strategy.”

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McConnell said he'd met with House Minority Leader Nancy Pelosi (D-Calif.) on Wednesday morning about issues on which the parties could find common ground. Pelosi also sang a bipartisan tune. "Voters delivered a resounding mandate about Medicare, Medicaid and preexisting conditions," Pelosi told reporters. "We will strive for bipartisanship. We believe we have a responsibility to seek common ground. Where we can, we will stand our ground."

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So did Trump, saying, "We want to do something on health care; they want to do something on health care. There are a lot of great things that we can do together.”

OOF: Attorney General Jeff Sessions resigned at Trump's request, the first such move in an expected post-election administration shake-up.

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Our Post colleagues Devlin Barrett, Matt Zapotosky and Josh Dawsey have the play-by-play: “Sessions received a phone call Wednesday morning from White House Chief of Staff John F. Kelly — before the president held a news conference to discuss the midterm election results — telling him the president wanted Sessions to resign, an administration official said,” they write. “Sessions sought to stay on the job at least until the end of the week, according to people familiar with the discussion. Kelly firmly rejected that suggestion, insisting Wednesday would be his last day, the people said. Sessions canceled meetings and scheduled one for later in the day, where he would say goodbye to his staff.”

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Sessions’s legacy includes his aggressive approach to law enforcement and drug policy. “Law enforcement officials in local communities also point to the aggressive approach Sessions has taken to fighting crime, both with his rhetoric and a string of new initiatives, particularly focused on the country’s opioid crisis,” our colleagues Sari Horwitz, Barrett and Zapotosky report. “The Justice Department, for example, has tripled its prosecutions of fentanyl cases and last year brought the first cases charging Chinese nationals with selling large quantities of the drug to Americans … He created a team of agents and analysts to disrupt illicit opioid sales online and started a unit to target opioid-related health-care fraud.”

Some drug policy groups jumped on the news of Sessions's exit to call for his successor to forge a different agenda. "The Justice Department and Senate should seize this opportunity to right Sessions’ wrongs,” Maria McFarland Sánchez-Moreno, executive director of the Drug Policy Alliance, said in a statement. “The U.S. public understands that the drug war has failed spectacularly and needs to be replaced with a health-centered approach. It is critically important that the next Attorney General be committed to defending basic rights and moving away from failed drug war policies.”

OUCH: Democrat Andy Kim declared victory in his New Jersey race to unseat Rep. Tom MacArthur (R), who was instrumental in helping House Republicans push through a bill to repeal the ACA. As of this morning, Kim was leading the race by less than a percentage point, though it has not been called.

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“We have built a substantial lead. I am proud to announce that we have won,” Kim told a group of supporters Wednesday, Politico’s Katherine Landergan writes. “This, from the very beginning, was always about the people, about what we wanted to do for our families, what we can do for our communities, making sure we have a voice in Washington that looks out for all of us.”

MacArthur has not conceded. The New Jersey Republican was the author of an amendment that helped pass the House Republican bill to repeal Obamacare before the effort floundered in the Senate. But in an election where most voters said health care was their most important issue, MacArthur faced ire from constituents.

Kim declared victory hours after “election officials in Burlington County, home to some of the district’s suburban communities, had finished counting thousands of vote-by-mail ballots,” Katherine reports. Still, just 99 percent of the precincts had been reported.

“I have always said that I will be guided by the voters of the district and there are nearly 7,000 more of them who haven’t been heard from yet,” MacArthur said in a statement. “We must ensure that their votes — and all votes — are counted in a transparent way that protects the integrity of this election."

AGENCY ALERT

— It's been one week since Healthcare.gov opened for its sixth enrollment season, and we're watching to see whether sign-ups hold steady even through Republicans have ditched the penalty for lacking coverage.

In the first three days, 371,676 people selected a plan, according to the first weekly enrollment snapshot released by the Centers for Medicare and Medicaid Services. The daily average sign-ups were 123,892, compared with 150,366 average daily sign-ups at the beginning of last year's enrollment period, per an analysis by Get America Covered.

But the group warned that it is too early to draw any conclusions about how this sign-up season will go.

— HHS announced it has finalized two federal rules that will allow employers with “religious or moral” objections to opt out of offering employees birth-control coverage, providing a much broader exemption from that ACA requirement than allowed by the Obama administration.

"The rules notch a deep exception to a federal requirement under the Obama-era interpretation of the Affordable Care Act that essential health benefits must include coverage of contraception at no charge to consumers," our Post colleague Amy Goldstein reports. "The Trump administration's move, after first proposing the change a year ago, aligns with “the administration’s alliance with social conservatives for whom ‘religious liberty’ has become a central cause and who had objected to the contraceptive mandate."

The finalized rules are amended versions of the drafts that “drew vehement protests from civil liberties and women’s rights advocates, along with Democrats in Congress and in state attorneys general offices,” Amy writes.

The initial proposals sparked two lawsuits that prompted federal judges in California and Pennsylvania to grant nationwide injunctions. All the cases regarding the draft rules are now before appellate courts.

HEALTH ON THE HILL

— More candidates with science, medicine and engineering degrees ran for Congress than ever before this midterm cycle, and at least seven of the candidates from STEM fields won seats in the House.

Some of those winners include Lauren Underwood, a registered nurse who also worked as an HHS adviser in the Obama administration; Sean Casten, a biochemist, who flipped a longtime Republican district in Illinois; and dentist Jeff Van Drew, who won a seat in New Jersey's 2nd district, our Post colleagues Sarah Kaplan and Ben Guarino report.

“Rep. Eddie Bernice Johnson (D-Tex.) is poised to take control of the House Committee on Science, Space and Technology,” they write. “Johnson was the first registered nurse elected to Congress, and will be the first chair of the committee with a STEM background since the 1990s, when it was led by former engineer George Brown (D-Calif.).”

INDUSTRY RX

— The results of the midterm elections appeared to give the health-care industry a boost, as industry stocks rose markedly Wednesday. Health insurance companies saw a spike after success from House Democrats effectively made it impossible for Republicans to now repeal the ACA.

“Marijuana companies soared after several states voted to partly legalize pot,” the Associated Press’s Marley Jay reports, “and a dialysis services company rocketed higher after California voters rejected a measure that would have capped the profits of dialysis clinics.”

— And here are a few more good reads from The Post and beyond:

TRUMP TEMPERATURE

REPRODUCTIVE WARS

MEDICAL MISSIVES

DAYBOOK

Today

Brookings Institution holds an event on the results and implications of the midterm elections.

American Enterprise Institute holds an event on postelection analysis.

The Food and Drug Administration holds its “Vaccines and Related Biological Products Advisory Committee Meeting ."

Coming Up

Friday. The American Medical Association holds its research symposium on

SUGAR RUSH

How environmental ballot initiatives fell short in the midterms: