This year could turn out to be a major turning point in US health reform politics. The Affordable Care Act’s (ACA) future will largely hinge on which party controls Congress and the White House as a result of the 2018 and 2020 elections. Maybe things will calm down, and the fight over the ACA will finally feel settled. Or maybe a coalition will emerge on the right with enough political will to repeal more of the law. 

The ACA’s reliance on federalism, both from how it was written and how it has been implemented by federal agencies and the courts, means that states will play a major role, regardless of the federal government’s direction. Even the dismantling of the ACA would demand a lot of state leaders. State elections this year are therefore enormously consequential. They also happen to set the stage for the 2020 state elections, which will determine how congressional and state legislative district lines are drawn for 10 years. 

The Tea Party wave in 2010 ushered in a decade of dominance for Republicans at the state level. Republicans currently control both chambers in 32 states and hold both chambers and the governor’s office in 26 states. Democrats have full control of only eight states. Many of the leaders that came into office in 2010 are now term-limited from running, meaning that this is the first time during the ACA era that power will change hands in many key states. Thirty-six states will hold gubernatorial elections this fall. Of those races, 13 are taking place in states that have not expanded Medicaid. So far, 33 states and the District of Columbia have expanded Medicaid, and for many of the remaining states, Medicaid expansion is at the forefront of election debates. 

We have our eyes on Florida and Maine in particular. Both states have since January 2011 been led by Tea Party governors who have resisted implementing the ACA. The 2018 elections could open the door to Medicaid expansion in both states. 

Florida

Expanding Medicaid in Florida—along with Texas—is one of the holy grails for supporters of the ACA. According to a recent report from the Centers for Disease Control and Prevention, Florida has the third highest percentage of uninsured adults in the United States at 20.1 percent. This is a huge number in such a populated state. In fact, 9 percent of all uninsured people in the United States live in Florida. If Florida were to expand Medicaid, an estimated 384,000 people would be eligible for coverage, second only to Texas. 

A crowded field of 12 Republicans and six Democrats will compete in the August 28 primary for each party’s nomination for governor. Medicaid is a major issue in the race, with 65 percent of Florida voters saying that they support expansion. The Democratic frontrunners—former Congresswoman Gwen Graham and former Miami Beach mayor Phillip Levine—both support expansion. Both Republican frontrunners—state senator Ron DeSantis and former Congressman Adam Putnam—oppose expansion. Polls for the primaries and the general election in November are calling this a toss-up. 

Whoever is elected will have to work with a legislature in transition. Democrats are unlikely to retake the House but only need a net gain of five seats to win control of the Senate. Half of the Republican-controlled senate is up for election, leaving 20 seats at risk. Of those seats, Republicans have to defend 15, giving Democrats the opportunity to gain control of the upper chamber. Reliable polling is not available at the state level, although political analysts project that Florida’s legislature is one of the likeliest to switch party control in 2018. 

Maine

No state has come closer to expanding Medicaid (without actually doing so) than Maine. Governor Paul LePage has six times vetoed legislation that would have expanded Medicaid. A referendum in 2017 to expand Medicaid to 70,000 Mainers was passed, and the courts have ordered Governor LePage to comply, but he continues to refuse. This deadlock may not be broken until a new governor and legislature takes office in January 2019. 

Maine is for the first time using a ranked choice voting system in which candidates with the lowest vote totals are removed from consideration until someone has a majority of ballots cast. LePage’s victory in a three-way race in 2010 with only 37.6 percent of the vote was part of the impetus for switching to ranked choice voting. 

Business leader Shawn Moody won the Republican nomination for governor outright with 52.6 percent of the vote. He is a vocal opponent of the Medicaid expansion and has said he would continue LePage’s resistance. Attorney General Janet Mills emerged as the Democratic nominee after four rounds of ballot counting. She is an outspoken supporter of Medicaid expansion. The Cook Political Report projects this race to be a toss-up. 

The ability of either candidate to advance their agenda if they become governor will depend on what happens in the state legislature, with both chambers at risk of shifting parties. Democrats need to pick up one seat to flip the Senate, while Republicans need to pick up three seats to gain control of the House. Due to term limits in both the House and Senate, Republicans are on the defensive with seven seats at risk in the senate and 14 at risk in the house. However, many of the Democratic seats up for election are in districts that voted for Donald Trump, which could signal potential Republican wins in those areas.           

Trump Effect?

State races are particularly hard to forecast in 2018 because it is still unclear what effect President Trump will have. Democrats are hopeful that last year’s victories in Alabama, New Jersey, and Virginia are a sign of a blue wave. Whatever happens, change is coming. Over the next few months, look to Maine and Florida as the two major battlegrounds for Medicaid expansion. The outcomes of these elections will have extensive implications for the future of health care reform in the United States.