Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, recently criticized the Medicaid program’s expansion under the Affordable Care Act in sharp terms: “We’ve put more than 10 million people, 12 million people into this program where the doctors won’t see them, and the policies that are in the Medicaid program are not designed for an able-bodied individual.”

Maine voters disagreed with the Administration’s position yesterday, voting overwhelmingly to expand Medicaid in their state by a vote of 59% to 41%. The expansion will enable 70,000 Maine residents to get health coverage. These adults are low-income and a majority are members of working families with jobs in agriculture or service industries or small businesses. Earlier estimates put the number of parents who would gain coverage through an expansion at about 15,000.

Maine was the first state to approve Medicaid expansion via referendum as well. Utah and Idaho are attempting the process of putting Medicaid expansion on the ballot, although their efforts are in the early stages. It is important to note that Maine’s expansion won’t happen immediately. Maine’s Governor, a longtime expansion opponent, is likely to try to delay implementation. This is no small threat as around the country there have been Governors and lawmakers who have tried with varying degrees of success to block implementation of voter-approved ballot measures.

In Maine, the state legislature just this year successfully blocked and changed several ballot measures previously approved by voters. However, the Maine legislature is already on record with multiple votes in favor of Medicaid expansion so implementing the voter’s decision, while taking some work, is considered likely to happen. These decisions are ultimately political, and yesterday’s overwhelming support for Medicaid expansion across the state – especially in rural areas – is a strong indication of the peril for politicians of trying to block expansion after the voters have spoken.

Another positive development: Expect rural hospitals that played a major role in the debate over Medicaid expansion to also move toward ensuring that the decision made by Maine voters is implemented in the state.

There will be ripple effects in other states around this expansion decision by voters. North Carolina, Georgia, Tennessee, Idaho, Kansas and especially Virginia should expect more robust debates on expansion this year. These states all have had serious discussions around expansion over the last few years and the election results in Maine and Virginia are an indication that affordable health care continues to be a popular topic. Maine’s vote is also a huge rebuke to efforts by Congress and the President to make enormous cuts to Medicaid nationally as part of efforts to repeal the Affordable Care Act this year.

Finally, there is irony in the fact that the Trump Administration trying to limit access to Medicaid coverage while voters in Maine clearly want access to Medicaid coverage expanded. Just this week, Administration officials indicated support for multiple barriers states might use to reduce enrollment in Medicaid. And officials scrubbed the federal website on state Medicaid waivers to remove the goal of expanding coverage.

Maine voters have spoken with strong support for simple, affordable health care. Closing state coverage gaps using Medicaid is clearly an issue that isn’t going away.