Whoever is elected president today could have a profound impact on the future of the U.S. health care system.
However, the future of health care will also largely be shaped by thousands of races for state offices around the country.
There are a number of very clear opportunities for voters to choose a specific direction on health care, such as in Colorado, where a ballot initiative that faces an uphill battle proposes establishing the first state-run single-payer health care system, or in Arizona and Washington state, where ballot initiatives that are likely to succeed will require businesses to provider workers with paid sick leave.
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Voters in five states (California, Massachusetts, Maine, Nevada and Arizona) will also decide whether to legalize recreational marijuana, while voters in four other states (Arkansas, Montana, North Dakota and Florida) will vote on whether to legalize medical marijuana.
But the bigger impact on U.S. health care will likely come from the indirect effect of voters electing Democrats or Republicans to run their state governments.
State governments have a significant say in what type of Medicaid program will be available to low-income residents.
That has always been the case, with some states classifying far more residents as eligible, but the distinction was made even clearer as a result of the Affordable Care Act's Medicaid expansion.
In states that participate in the expansion, all residents below 133 percent of the federal poverty level are eligible for free or near-free Medicaid coverage, which is almost entirely paid for by the federal government.
Because of fierce GOP opposition to the ACA, most Republican-run states refused to take part in the expansion as the ACA was rolled out three years ago.
However, since then, a number of states have reversed their positions and belatedly embraced the expansion.
Medicaid expansion advocates have an opportunity today to bring even more states into the fold. Similarly, opponents have a chance to scrap an existing expansion program.
According to Modern Healthcare, if Republicans win key races in New Hampshire, Montana and North Dakota, they might be able to reverse an expansion that was previously put in place.
Conversely, there are 17 states that have not expanded Medicaid, but could do so next year if Democrats make gains in the state legislature or win the governor's race.
To be clear, most of these states are solidly Republican states where Democrats don't have much of shot at taking total control of state government, but if they increase their share of the legislature or win the governorship they might be able to push Medicaid expansion through collaboration with some pro-expansion Republicans.
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