For nearly a decade, opposition to former President Barack Obama's health care law has been a winning message for Republicans.
But this year, residents in several conservative states are bypassing legislatures that have refused to expand Medicaid, one of the pillars of Obama's health overhaul.
Voters in three Republican-dominated states - Idaho, Nebraska and Utah - will decide in November whether to expand the health insurance program to more lower-income Americans.
A ballot initiative in a fourth state, Montana, seeks to raise a tobacco tax to keep funding a Medicaid expansion that is set to expire.
Medicaid also has become a focal point for governor's races in states that did not accept the expansion, including in Florida, Georgia and Tennessee.