The midterm elections could bring sweeping changes to Medicaid, from possible eligibility expansions to new rules requiring low-income people to work, depending on voters’ choices for governors’ offices and state legislatures across the country.

Medicaid covers more people than any other federally funded health program.

Medicaid expansion advocates are optimistic that voters in Idaho, Nebraska and Utah will pass ballot initiatives to broaden coverage, buoyed by strong polling numbers and the fact that petitions in those states to force ballot votes garnered tens of thousands of more signatures than needed. Experts say other states, such as Kansas and Georgia, could expand eligibility, depending on the electoral outcomes, especially if conservative priorities such as work requirements are added.

Uncertainty around the future of Medicaid expansion emerged in recent years because of court challenges and Republican efforts to repeal the 2010 health care law, but states that put their expansion discussions on hold are now revisiting their thinking, said Ben Sommers, associate professor of health policy and economics at Harvard University.

“States are going to be back in this game, and we may see the steady trickle (of expansions) resume,” Sommers said.

If approved by voters, expansions in Idaho, Nebraska, and Utah would extend health insurance to more than 300,000 low-income people. Meanwhile, in Montana, another ballot initiative, if approved, would renew the state’s existing expansion, which covers nearly 100,000 people though it expires next year.

It’s possible that Florida and Missouri could hold expansion ballot initiatives in 2020, said Kelly Hall, director of health policy and partnerships at The Fairness Project, a group promoting ballot initiatives.

Watch: All You Ever Wanted to Know About Health Care Ahead of the 2018 Midterms

But experts note that a vote for expansion by ballot initiative doesn’t necessarily mean an easy path forward if state officials balk. Take the case of Maine, where Republican Gov. Paul R. LePage refused to implement expansion after nearly 60 percent of voters passed an expansion ballot initiative in 2017. The state Supreme Court ordered him this summer to move forward, but even now, the state is slow-walking the process with implementation likely to wait until next year at the earliest when LePage’s term ends.

Gubernatorial candidates competing to replace LePage are in favor of Medicaid expansion — Democrat Janet Mills and independents Terry Hayes and Alan Caron all support expansion. Republican Shawn Moody, while initially indicating that he would follow LePage’s lead in opposing it, recently said he will follow the law and expand as long as funding is available.

Earlier this week, the Centers for Medicare and Medicaid Services appointed former Maine health commissioner and staunch Medicaid expansion opponent Mary Mayhew as deputy administrator and director of Medicaid and the Children’s Health Insurance Program, the top federal official overseeing the program. The agency said Mayhew will recuse herself from decisions related to Maine.

Experts say it would be politically dicey if governors in any states that pass expansion this year ignore their constituents’ will.

In Nebraska, advocates are confident a Maine-like situation won’t arise if voters approve expansion.

“The ballot language that voters will be deciding on was carefully crafted to avoid the exact issue that Mainers have run into with Gov. LePage,” said Meg Mandy, campaign manager for expansion advocacy group Insure the Good Life.

Republican Gov. Pete Ricketts, who is up for re-election in the Cornhusker State, opposes expansion but said he will let voters decide. But a former state lawmaker and current state senator who unsuccessfully sued to prevent the question from being on the ballot suggested further legal action could be taken if voters approve it.

The November elections could also affect expansion in other red states.

Kansas state lawmakers passed expansion legislation last year only to have it vetoed by then-Gov. Sam Brownback, a Republican. His successor, Jeff Colyer, also opposed the idea. But a close race for the governor’s seat this year could upend that.

Democratic candidate Laura Kelly and independent Greg Orman both favor expansion, while Republican Kris Kobach is opposed.

Health care experts are also monitoring Georgia and Florida, where expansion is a hot topic.

Democrats might not need a legislative majority to move on expansion in some states, said David Jones, an assistant professor at Boston University’s School of Public Health. They just need enough seats to pressure moderates who could help them cobble together a coalition, he said.

That occurred earlier this year, when Virginia lawmakers voted to extend Medicaid coverage to roughly 400,000 low-income adults, following a 2017 electoral upset that gave Democrats 15 more seats in the House of Delegates. The shift left Republicans with razor-thin margins in both chambers.

After that, moderates were more willing to accept expansion, Democratic Gov. Ralph S. Northam said Thursday at a national conference in Washington. The lingering effects of the recession, struggling rural hospitals’ calls for expansion and the opioid crisis also fueled support for broadening Medicaid, Northam said.

Experts say similar changes in state legislatures could ultimately propel holdout states closer to expansion. Seventeen states have not adopted expansion, according to the Kaiser Family Foundation.

“Florida in some ways is the holy grail of Medicaid expansion,” said Jones of Boston University. “If that were to flip, I think it would be a huge moment for Medicaid.”

The chances of that are remote, however, even if a Democrat becomes governor, because Republicans still have the upper hand in the state legislature. Democrats are unlikely to take the Florida House but might pick up Senate seats, Jones said.

Incoming Florida Senate President Bill Galvano told the Miami Herald last month that he does “not believe there is support in the legislature for the expansion of Medicaid contemplated in the Affordable Care Act.”

Georgia is another red state where the forecast is iffy.

Expansion became a focus of the state’s gubernatorial race with Democrat Stacey Abrams, a former leader in the legislature, ardently supportive and Republican Secretary of State Brian Kemp staunchly opposed.

Even with an Abrams win, expansion advocates would face an uphill battle in the GOP-controlled legislature. However, some conservatives — particularly those from rural regions where hospitals are struggling — expressed tentative support in the past.

Georgia is analogous to Virginia in the level of voter support for expansion, said Patricia Boozang, a health care expert with consulting firm Manatt, Phelps & Phillips. The rural health issue is a big factor.

Boozang added that if some red states do expand, they may add conservative-friendly elements, such as work requirements, like Virginia did.

The November elections could also spur changes in how states run their existing programs.

A Democratic gubernatorial win in a state such as Michigan might lead the state to reconsider its proposal to add work requirements to Medicaid, Boozang said.

But in more conservative states, elected Republicans could push for more work requirements and other changes, Jones said. Kentucky is one example of how new leadership led to rollbacks, he said.

Republican Gov. Matt Bevin asked federal officials to operate Kentucky’s state-run insurance exchange and threatened to end Medicaid expansion. While he ultimately didn’t eliminate expansion, Bevin did pursue significant changes, including work requirements.

Governors and legislators in states seeking work requirements, such as Arizona, Michigan and Ohio, play important roles in shaping those rules, Jones said. While work rules share similarities, they vary on key issues such as the number of hours people must work or whether individuals who fail to meet the requirements are locked out of coverage.

Full-on repeals of expansion are politically unpalatable since Medicaid is popular among voters, Sommers said. But a newly elected Republican governor could push for work requirements, which are also popular even among some Democrats, he said.

“It has much less public outcry,” he said. “It’s a much less contentious stand to take.”

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LAS VEGAS — The start of early voting in Nevada always brings out the stars, and 2018 was no exception.

President Donald Trump concluded a western swing Saturday morning with a rally in the remote city of Elko just after former Vice President Joe Biden fired up Democrats here in Las Vegas in the crucial Senate race.

Trump and vulnerable GOP Sen. Dean Heller urged the GOP faithful in rural Nevada to get out and vote early.

“You know, a big portion of your state does do early voting, which is surprising. Very unusual,” the president said. “But you’re a very unusual state.”

Nevada is not the only state where significant numbers of voters cast their ballots ahead of Election Day.

Heller argued that high turnout among early voters outside Clark County — which accounts for almost three-quarters of the state’s population and includes Las Vegas — could send a message to the Democrats and the campaign of his challenger, Rep. Jacky Rosen.

Heller and state Attorney General Adam Laxalt, the GOP nominee for governor, were invited to join Trump onstage separately, and the two men had nothing but praise for the president.

“Mr. President, you know a little something about gold. In fact, I think everything you touch turns to gold,” said Heller, noting the gold mining production in nearby Eureka County.

Meanwhile, more than 300 miles to the south in Las Vegas, Biden said Democratic control of Congress wasn’t just about moving forward on the party’s priorities.

“My name is Joe Biden and I work for Harry Reid,” the former vice president said, opening his remarks by invoking the name of the former Senate majority leader and de facto party boss of Nevada Democrats.

Lamenting that Republicans were, in his view, “putting their party over their country,” the potential 2020 presidential contender said a Congress run by Democrats could change that. 

“When we win back the House and the Senate … you’re going to see somewhere between 15 and 20 Republicans in the House starting to vote their conscience when they know it can matter,” Biden told supporters gathered here outside the Culinary Workers Union on the first day of early voting. “And you’re going to see between three and six Republicans in the Senate begin to vote the right way.”

“They don’t want to be the only guy out there on that deciding vote. And if they know the consensus of the body is to do the right thing, they will join,” the former vice president said. 

Trump joked about the differing crowd sizes between the Nevada State Democratic Party event with Biden and his Elko rally, but in some respects the two men had different intentions. Biden was in town to fire up members of the powerful Culinary union, which has proved to be the engine of the Democratic ground game.

In contrast to the diverse group of workers behind the Las Vegas tourism business, when Trump asked his Elko rally crowd about Hispanic turnout there, the response was less than tepid.

“Eh, not the most, not the most. I’d give it 5 percent,” he said. “That’s OK.”

Back in Las Vegas, Biden predictably voiced support for Rosen, who faced off against Heller in their first and only debate of the campaign the previous night. Polls have shown a tight race. 

The Silver State is the Democrats’ best pickup opportunity in the Senate this cycle, with Heller the only Republican facing a competitive race in a state  Trump lost in 2016. Inside Elections with Nathan L. Gonzales rates the contest a Toss-up. 

Biden said the lack of consensus in Congress had caused power to flow to the presidency.

“The House and Senate become irrelevant, which they basically have,” he said. “And that’s when you see this incredible abuse of power.”  

Biden, who also represented Delaware in the Senate for 36 years, issued a sharp rebuke of Trump, accusing him of sullying the country’s reputation around the world. He blasted Trump’s foreign policy and accused him of purposely dividing the country. 

And he told supporters this was the most consequential election in recent memory. 

“We’re in a battle for the soul of America, folks,” the former vice president said as the morning sun beat down on the crowd.

Watch: House GOP Candidates Are Shying Away From Trump As Midterm Nears

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A majority of individuals rank health care as a “very important” issue in determining who they plan to vote for, according to a new poll that looks at prospective voters nationally as well as in two key battleground states.

Thirty percent of those polled nationally selected health care as the “most important” issue, outranking the economy, immigration, and gun policy, according to data from the nonpartisan Kaiser Family Foundation.

However, the importance of health care to voters’ support fell along party lines. Democrats and independents viewed health care as a more important issue than Republicans.

Forty percent of Democrats and 31 percent of independents ranked it as the top issue, while only 17 percent of Republicans did.

Republicans’ top issues were immigration (with 25 percent ranking it first) and the economy and jobs (23 percent).

Voters especially have concerns with the climbing costs of prescription drugs and access to care. Of those surveyed who ranked health care as “very important,”24 percent view rising costs and 19 percent said access to care as the issue most important to them. Only 4 percent cited proposals to switch to a government-run system such as Medicare-for-all.

Trends in Florida and Nevada, two states with tight Senate and gubernatorial elections, mostly mirror the national survey data.

Health care ranks as the top issue for 26 percent of Florida voters, where Democratic Sen. Bill Nelson is fighting to keep his seat from Republican challenger Rick Scott, the current governor.

In Nevada, health care ranks among the top issues for 24 percent of people polled alongside immigration (23 percent of respondents) and the economy and jobs (21 percent). Sen. Dean Heller, a Republican who voted to repeal the 2010 health care law ( PL 111-148 , PL 111-152 ) last year, is in a tight race with Rep. Jacky Rosen, a Democrat.

Majorities of voters in both states said they are likely to support a candidate who wants to maintain the health care law’s protections for individuals with pre-existing conditions.

Heller supports a bill (S 3388) that would attempt to protect these protections if the health care law is struck down by the courts. Twenty state attorneys general are currently suing to have these protections overturned in Texas v. Azar.

In addition to pre-existing conditions, voters are concerned with Medicaid expansion, rising drug costs and expanding health care access.

Florida is one of 17 states that did not expand Medicaid, while Nevada expanded its program in 2014. Forty-nine percent of Florida voters want to vote for a candidate who supports expanding Medicaid, while 28 percent want to keep the program as is. The Republican candidate for governor in Florida, former Rep. Ron DeSantis, is against Medicaid expansion, while his Democratic opponent, Andrew Gillum, supports it.

In Florida, 47 percent of voters support regulating the prices of prescription drugs while 23 percent oppose that. In Nevada, 39 percent of people polled support drug price regulation but 32 percent do not.

Voters in both states also slightly favor a national health care plan or Medicare-for-all. In Florida, 43 percent of individuals support such a plan while 33 percent oppose it. Gillum supports a national health plan, but the policy is not likely to move forward in a Republican-controlled legislature.

In Nevada, 47 percent would support a candidate in favor of a national health plan while 33 percent would oppose a candidate with this view.

The survey results were conducted by the Kaiser Family Foundation from Sept. 19 to Oct. 2 among a nationally representative random telephone sample of 1,201 adults, and a representative sample of 599 Floridians and 599 Nevadans.

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An Interior Department watchdog found that Secretary Ryan Zinke violated federal policy when he let his family members travel with him in government vehicles, although he had reimbursed the department.

A copy of the department’s inspector general report was sent to Congress and was provided to Roll Call by a congressional aide on Thursday.

The inspector general’s office reached its findings after investigating allegations that Zinke had made numerous trips, including in private and military jets, at taxpayer expense.

Rep. Raúl M. Grijalva of Arizona, the top Democrat on the House Natural Resources Committee, which oversees the department, complained that “Republicans have known about Secretary Zinke’s scandals for 18 months and done nothing.”

Zinke had also asked Interior Department employees about whether his wife could join the department as a volunteer, according to the IG.

“He denied that his intention in making this request was so that his wife could travel with him in an official capacity, which would have eliminated the requirement to reimburse the Government for her travel,” the report said. “Ultimately, the employees advised him that making her a volunteer could be perceived negatively, and she did not become one.”

Zinke also cost taxpayers $25,000 when he took an unarmed security detail with him during a vacation to Turkey and Greece, the IG said in its report.

The report comes as the Interior Department is dealing with public backlash over news reports that Zinke had attempted to hire Suzanne Tufts, a political appointee at the Department of Housing and Urban Development, to serve as Interior’s acting inspector general. The Interior Department has since denied any such move and blamed it on an incorrect email sent by HUD Secretary Ben Carson, according to The Washington Post, which reported on the IG report earlier Thursday.

The IG’s investigation also found that Zinke in March 2017 directed his security detail to drive someone who was not a government employee to the airport after a dinner, against agency rules.

“Secretary Zinke acknowledged that he told his detail to take the non-Government employee to Reagan National Airport,” the report said. “He said he had asked this as a matter of convenience, but he was later told not to make such requests and he has not done so since.”

The agency cleared Zinke of allegations that a department employee had resigned over requests that she walk his dog. The employee told the investigators she walked Zinke’s dog voluntarily and had instead resigned because she did not receive a position she wanted.

“The Inspector General report proves what we have known all along: the secretary follows all relevant laws and regulations and that all of his travel was reviewed and approved by career ethics officials and solicitors prior to travel,” Interior spokeswoman Heather Swift said in an email. “Concerning the internal travel policy, that has been updated to reflect the reality of the long standing situation.”

Democrats and environmental groups have for months been frustrated over the refusal by the Republican majority to hold oversight hearings to examine the spending and travel habits of Trump administration officials, including Zinke and former EPA Administrator Scott Pruitt, who resigned amid a long list of spending and management scandals.

The latest report on Zinke is likely to cause them to amplify calls for oversight and for his resignation, although the White House has not given any indication that it would fire Zinke.

“Being exposed for abusing his power to rip-off the taxpayer while benefiting himself provides all the proof that should be needed to fire Ryan Zinke,” Sierra Club Executive Director Michael Brune said in a news release. “It’s time Donald Trump fires Ryan Zinke, not give him a chance to engage in a Washington cover-up.”

Watch: Trump Heads West to Campaign — And a Lot of Senators Do, Too

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At a listening session with inmates recovering from substance abuse this week, Rep. Dave Brat pivoted the conversation to his own re-election race.

“You think you’re having a hard time — I’ve got $5 million worth of negative ads coming at me,” the Virginia Republican said. “How do you think I’m feeling? Nothing’s easy. For anybody.”

“You think I’m a congressman, ‘Oh, life’s easy, this guy’s off having steaks every day.’” he went on. “Baloney. I’ve got a daughter, she’s got to deal with that crap on TV every day.”

“So it’s tough,” Brat continued. “No one out there’s got some easy life. Right?”

The gaffe comes as Republicans across the country look to cast their action on opioid addiction as a key legislative achievement before the midterms. Brat’s opponent, Democrat Abigail Spanberger, called his remarks “an affront to every person in recovery and the Virginians who die daily due to their addiction.”

Spanberger also pointed to Brat’s vote for the American Health Care Act, which would have hampered states’ ability to respond to public health crises like the opioid epidemic, according to the Kaiser Family Foundation.

Brat’s star rose after his surprise upset of former House Majority Leader Eric Cantor in 2014, but he faces a tough re-election challenge this cycle: Inside with Nathan L. Gonzales rates the race a Toss-up.

The inmates Brat stressed how poverty and a punitive criminal justice system are obstacles to recovery, according to a report by WCVE, a public radio station in Virginia. One woman shared that she’s entered into 90-day inpatient substance abuse treatment programs without knowing where she’ll live after those 90 days are over.

It's worth noting Brat later acknowledged the inmate was up against steeper problems. Here's a longer cut for more context. pic.twitter.com/80hTiZWAua

But Brat appeared to emphasize personal responsibility in his response, according to an audio recording, encouraging inmates to “find a substitute for drugs, be it exercise, or academics, or reading books, going to the Bible, you gotta find something.”

Brat acknowledged that facing attack ads in pursuit of public office is not as difficult as coping with substance abuse: “You got it harder, I’m not dismissing that,” he’s heard saying later.

Still, critics say Brat’s comments show he doesn’t understand how serious the opioid crisis is. A record 1,227 people died from opioid overdoses in Virginia last year, the fifth straight year of record fatalities, according to a Virginia Department of Health report.

Kim Myers, an employee of the prison’s recovery program, said she felt “attacked” by Brat’s comments.

“How could you compare yourself to someone who’s going to get out and not be able to get a job, and not be able to get housing, and has to pay all these fines and restitutions for being in jail?” she told the radio station.

But not everybody at the listening session felt that way.

Chesterfield County Sheriff Karl Leonard, who introduced the prison recovery program, posted on Facebook that he regrets the low-key visit became political fodder.

“A sitting Congressman, who was trying to make a difference in the lives of those struggling with addiction by learning more about it directly from those dealing with the disease, is now being portrayed in such a negative and distorted way,” Leonard said. “The real losers here will be the people struggling with addiction inside our jail and across this Nation, now who become an afterthought and a forgotten part of the story.”

Brat has dealt with the fallout from the gaffe by touting President Donald Trump’s recent endorsement — he referred to the congressman as “strong on crime” — and and by invoking scripture.

“As a Christian, we love the least of these — we visit those in prison,” he said in a statement. 

Watch: Brat Echoes GOP's Nancy Pelosi Attack Line in Virginia Debate

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Lawyer Laura Mills released a statement Thursday through Ohio Republican Senate candidate Jim Renacci’s campaign providing more details on a sexual misconduct allegation against Sen. Sherrod Brown stemming from an incident in the late 1980s.

The Ohio Democrat has previously called Renacci’s unsubstantiated claims of improper sexual conduct by him “desperate.”

But Mills’ statement Thursday, first reported by Cleveland.com, marks the first time Renacci has provided more than just hearsay knowledge of a claim against Brown.

Mills is a former business partner of Renacci and a donor to his past political campaigns.

She describes her client as a woman who met Brown “in the course of her work” and found herself one time alone with him, “but not on a date,” Mills’ statement reads.

The alleged incident occurred in the late 1980s, between Brown’s divorce in 1987 from his first wife and his marriage to his current wife.

At their meeting, Brown allegedly made “an unexpected, uninvited, unwanted, and sudden advance” toward the woman, “roughly pushing her up against a wall,” Mills said.

The woman “told a friend in confidence about her unwanted and unexpected experience in the late 80’s,” Mills said.

“This was months ago, shortly after the MeToo movement began. The reason she told her friend was to explain why she believed many of the women, as something unwanted had happened to her with a prominent politician. She had no intention of coming forward and did not know that the friend would later contact Jim Renacci with it.”

Renacci referred the woman to Mills.

Brown has issued a cease and desist letter to Renacci in which he advised the Ohio Republican not to “continue making unsubstantiated and false claims about something that never happened,” or else he would face “legal ramifications,” a spokesman for the senator, Preston Maddock, said in a statement.

Maddock highlighted Mills’ previous professional and political affiliation with Renacci and characterized her claims as “anonymous” and “unsubstantiated.”

“This will not be tolerated,” Maddock said, and “all legal means will be pursued against Jim Renacci.”

Brown’s lead over Renacci in the polls has never dropped below 13 points since the two won their respective primaries in May.

President Donald Trump defeated Hillary Clinton by 8 points in the quadrennial swing state in 2016. 

Still, Inside Elections with Nathan L. Gonzales rates the race for Ohio’s Senate seat Likely Democratic as Democrat Brown seeks a third term.

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