Three traditionally Republican states voted to expand Medicaid coverage under the Affordable Care Act. Voters in Nebraska, Idaho and Utah passed referendums that will grant coverage to individuals who earn incomes up to 138% of the federal poverty level. It’s been estimated that expansion in all three states could provide coverage for around 300,000 additional people.

A similar referendum to extend Medicaid expansion beyond a scheduled sunset in June 2019 failed in Montana. Montana’s referendum faced stiff opposition from the tobacco industry, as the measure proposed to offset a 10% reduction in federal funding through an increase in tobacco taxes. The state legislature could pass legislation to extend the sunset, but it is unclear if that will happen. In 2015, a bipartisan coalition narrowly passed the expansion in the state’s Republican-controlled legislature with support of Democratic Governor Steve Bullock. The Medicaid expansion in Montana has provided coverage to almost 96,000 people.

The results of the governors races in several states are also likely to impact Medicaid expansion. Three states that flipped to Democrats—Kansas, Maine and Wisconsin—have not expanded Medicaid under the Affordable Care Act (ACA). In Maine, voters passed a referendum requiring expansion in November 2017, but current Governor Paul LePage refused to implement the expansion. Governor-elect Janet Mills has stated she intends to implement the expansion. In Kansas, the legislature approved expansion in 2017, but that was vetoed by current Governor Sam Brownback. Governor-elect Laura Kelly made Medicaid expansion a central part of her campaign. In Wisconsin, Governor-elect Tony Evers will likely face resistance from conservatives in the legislature if he attempts to make changes to the state’s hybrid system, which did not expand coverage under the ACA but did expand coverage to individuals who earn incomes up to 100% of the federal poverty level. Wisconsin’s Republican Assembly Speaker Robin Vos has vowed the state will never accept federal funding for Medicaid expansion, but Governor-elect Evers, who campaigned on Medicaid expansion, has stated he will use legal means to challenge Speaker Vos and other conservatives.

Requests to implement work requirements under state Medicaid plans are also likely to be affected. In Wisconsin, where Centers for Medicare & Medicaid Services (CMS) recently approved the state’s work requirement request, Governor-elect Evers has stated his opposition to the requirements and will have the power to modify or withdraw the waiver. In Michigan, however, a state whose waiver request is currently under review by CMS, it is unlikely the gubernatorial flip will impact the state’s work requirement request if approved, as Michigan’s request was mandated by the legislature and requires legislative approval to be withdrawn.