Election day brought about one of the biggest single day state expansions of the ACA with voters in three states approving Medicaid expansion under the ACA and some new governors could push for more after they are sworn in next year.

Voters in Idaho, Nebraska and Utah all had ballot initiatives to expand Medicaid coverage through the ACA. All three ballot initiatives, which directs the states to take the expanded Medicaid option, won easy approval by voters in the three states. In Utah the legislature had passed and requested a modified expansion of Medicaid, but the ballot initiative did not have the work requirements and other limits the legislature had approved. Instead 54 percent of voters gave approval to a straight expansion. The expansion is estimated to cover 150,000 customers. In Nebraska the ballot initiative approval is expected to cover another 90,000 Nebraskans and the Idaho expansion is expected to cover 62,000 patients.

In addition to those states, the Maine initiative that had passed a year before will now get implemented. The current Maine Governor Paul LePage had refused the directive by voters and the courts to expand coverage and he will now be replaced after being term-limited. He will be replaced by Democrat Janet Mills. In two other states where Democrats will take over the governship, Wisconsin and Kansas could also be targets for expansion. In Wisconsin the now-defeated Governor Scott Walker had just received an ok from HHS and CMS to impose more work restrictions on Medicaid eligible customers. The new Governor-elect Tony Evers can now pull the waiver back and attempt to expand Medicaid. In Kansas Governor-elect Jeff Colyer is a physician and he replaces a more conservative executive office that under former Governor Sam Brownback has been facing voter reaction to past program and budget cuts.

After these states, 12 states have not taken the option, Wyoming, South Dakota, Oklahoma, Texas, Missouri, Tennessee, Mississippi, Alabama, Georgia, North Carolina, South Carolina and Florida.