Voters in the three Republican-controlled states passed Medicaid expansion ballot measures Nov. 6, potentially increasing coverage to an estimated 300,000 people and bringing the total number of expansion states to 36.

Ballot initiatives in Idaho, Nebraska and Utah approved by voters will increase Medicaid coverage up to 138% of the federal poverty level for individuals in those states. Montana voters, meanwhile, appear poised to vote down an initiative to extend Medicaid expansion, which could see Medicaid expansion sunset in the state in 2019.

Kate Wolfe, communication director for Insure the Goodlife, the grassroots organization that has led the Medicaid expansion effort in Nebraska, said that people have been fighting for Medicaid expansion for six years in the state. When the measure officially passed, "there was excitement ... and I would say, probably some relief."

Considering that all three of the initiatives that passed are in states with Republican-controlled state legislatures, proponents of expansion expect a challenge to ultimately achieving implementation of expansion. Maine was the first state to pass expansion via ballot initiative in 2017, and the program has yet to take effect.

Wolfe said that her state's initiative requires the Nebraska Department of Health and Human Services to submit an application for expansion by April 1, 2019, but supporters predict the legislature and newly re-elected Republican Gov. Pete Ricketts could slow the process.

"When full implementation happens, that can be where it could get sticky," Wolfe said.

Medicaid expansion could expire in Montana

Montana, which was voting to continue Medicaid expansion that was passed in 2015, is the only state that did not see its Medicaid expansion initiative pass. Medicaid expansion in Montana increased coverage to 100,000 people in Montana, about 10% of the state's population.

While the results have not officially been called by the Associated Press, about 54% of voters have opposed the ballot initiative with about 85% of votes tallied, according to data from AP.

Montana's ballot initiative was not a direct expansion of Medicaid. It would have increased the state's tobacco tax in order to fund the continuation of Medicaid expansion. However, the legislation was temporary and expansion will sunset June 30, 2019, if legislation to support it is not passed.

Of the four initiatives, Montana's saw some of the strongest organized opposition before election night.

Jonathan Schleifer, executive director for The Fairness Project, a political organization that has provided financial and analytical support to expansion efforts in each state, told S&P Global Market Intelligence in an interview before the election that big tobacco companies contributed $17 million to oppose the measure.

During a Nov. 7 call, Schleifer said that the organization is assessing which states to work with next on Medicaid ballot initiatives, but did not provide any specific details. All four initiatives bypassed the traditional route through the state legislature and made it on the ballot through petitions. Aside from Montana, only six states that can use this same strategy remain – Florida, Oklahoma, Mississippi, Missouri, South Dakota and Wyoming.

Kelly wins in Kansas, Gillum loses in Florida

The AP reported Nov. 6 that Democrat Laura Kelly defeated Republican candidate Kris Kobach in the governor's race in Kansas, opening the door for another Republican-leaning state to expand Medicaid.

In 2017, Kansas' state legislature passed a Medicaid expansion bill that would have increased coverage to about 150,000 people. However, it was vetoed by former Republican Gov. Sam Brownback, who left his position in January to become an ambassador.

Kelly campaigned on supporting Medicaid expansion and has said that she will sign the legislation if expansion is passed by the state legislature.

Florida and Georgia were both seen as Republican-leaning, Southern states that could expand Medicaid, considering both Democratic candidates used Medicaid expansion as a key issue throughout their campaigns. But Florida Democratic candidate Andrew Gillum lost to Republican Ron DeSantis, and Georgia's Democratic candidate Stacy Abrams was trailing Republican Brian Kemp by 1.8% on Nov. 7, according to the AP.

Wisconsin, which is the latest state to receive approval for Medicaid work requirements, could also be a key state for future Medicaid expansion. Democrat Tony Evers defeated Republican Gov. Scott Walker, the AP reported Nov. 7. Walker, who was seeking a third term, has been a critic of expanding the state-run healthcare program, while Medicaid expansion was part of Evers' platform.

Marijuana and the midterms

Four states had ballot initiatives to legalize either recreational or medical use of marijuana. Voters in Michigan passed legislation for recreational use, while voters in North Dakota voted against it, according to results from the AP.

The AP reported that voters in Missouri passed a measure that will allow the use of medical marijuana with a 4% tax. The measure was one of three on the ballot in Missouri, all of which had different tax provisions attached to them. The proposition that passed specifically states that the 4% tax will go to healthcare services for veterans.

Efforts to legalize medical marijuana in Utah are projected to succeed, according to the AP, with 53% supporting the measure with 76% of votes finalized.