Maine Gov. Paul LePage, a Republican, declared Thursday that he will go to jail before he allows the expansion of Medicaid in his state.

Six in 10 Mainers voted for a ballot initiative last November to expand eligibility for the program. But LePage has refused to respect the will of the voters and blocked all implementation efforts. The state House voted 85 to 58 on Monday to override his seventh veto of Medicaid expansion, but that was short of the two-thirds required.

A superior court judge has ordered LePage to submit a Medicaid expansion plan, but he’s refused. Maine’s Supreme Judicial Court will hear the governor’s appeal next week.

“The one thing I know is nobody can force me to put the state in red ink, and I will not do that,” LePage said in a radio interview yesterday, referring to the case. “I will go to jail before I put the state in red ink. And if the court tells me I have to do it, then we’re going to be going to jail!”

Medicaid for all this is not. The expansion LePage is willing to go to jail to resist, which was supposed to take effect at the start of July, would allow residents who earn up to 138 percent of the federal poverty level – an annual income of just $16,753 for individuals – to qualify for coverage. In Maine, that modest change would make about 70,000 additional poor people eligible for health care.

This has become the dominant issue in the Maine governor’s race. LePage is termed out. The winner of last month’s crowded Republican primary, whose spokeswoman is LePage’s daughter, has endorsed his hard-line approach. It could cost him the general election.

Across the country, Republican gubernatorial candidates have struggled to thread the needle on Medicaid expansion. Their base wants to destroy anything connected to Obamacare, but the general electorate supports Medicaid expansion by a large margin. A predictable pattern has emerged in some places: Candidates attack Obamacare when they’re trying to lock up the nomination and then backpedal on Medicaid in the general.

The failure of the Republican-controlled Congress to repeal Obamacare has created momentum in state capitals to accept money from the federal government, which offers to pick up 90 percent of the costs, to expand Medicaid. Virginia joined the herd in May after key GOP legislators from rural areas announced they couldn’t bear to deny coverage for their low-income constituents any longer and Democrats made massive gains in November’s off-year elections. There could be several referendums on the ballot this year like the one in Maine that would let voters decide whether to expand Medicaid, including in some of the reddest states in America.

In Ohio on Wednesday, Attorney General Mike DeWine – the Republican candidate for governor – embraced Medicaid expansion and called for adding work requirements. DeWine, a former U.S. senator, often said during the primary that the Medicaid expansion was “unsustainable” and attacked his Republican opponent, Lt. Gov. Mary Taylor, for supporting it.

The extension of health-care benefits to about 700,000 low-income Ohioans is the proudest achievement of outgoing Gov. John Kasich. Kasich said after the primary that he was holding off on endorsing DeWine until he received assurances he would continue the program, according to the Associated Press. The shift also helped DeWine lock down the endorsement this week of the Ohio State Medical Association PAC, the largest organization of doctors in the state. He’ll take any support he can get: Public and private polls show that the battle in the Buckeye State is close.

Democratic nominee Richard Cordray’s campaign tabulates that DeWine spent more than $1 million on ads before the Republican primary that attacked Taylor for supporting Medicaid expansion. “He’s a political opportunist who just can’t be trusted to protect our health care,” said Betty Sutton, the Democratic nominee for lieutenant governor and a former congresswoman who voted for the Affordable Care Act in 2010. “He’s spent 42 years running for office . . . It’s pretty clear his reversal is political.” We spoke last night as she drove from Steubenville to Columbus.

“It doesn’t take a rocket scientist to know that ripping health care away from hundreds of thousands of people is a bad general election message,” added Jared Leopold of the Democratic Governors Association. “Unfortunately for candidates like Mike DeWine, they can’t erase the videotape of opposing Medicaid expansion during the primary.”

In Minnesota on Thursday, Tim Pawlenty – looking to make a comeback – launched an attack ad against his Republican primary opponent on health care. Jeff Johnson is widely perceived as the more conservative alternative to the former governor, so Pawlenty is going negative before the August primary to portray his rival as weak on issues important to the base. Johnson was the GOP nominee for governor in 2014, and he said during an interview at the state fair that year: “I can’t repeal Obamacare.” He added, “We’ll still have [the Minnesota health care exchange] whether I like it or not.” That is the citation in the ad to justify this claim: “Jeff Johnson supported spending millions of taxpayer dollars to support Obamacare. Higher taxes. Wasteful spending. Supporting Obamacare. That’s the real Jeff Johnson.”

In addition to Ohio, two of the other most consequential governor’s races in 2018 are taking place in Michigan and Nevada. All three will be presidential battlegrounds in 2020. In each of them, a moderate GOP governor who was elected in 2010 – Rick Snyder, Kasich and Brian Sandoval – opted to expand Medicaid over the opposition of their right flank. In all three, the state’s Republican attorney general – elected separately – was involved in anti-Obamacare lawsuits. Each is now positioned to the right of their outgoing GOP governor on health care.

In Nevada, Attorney General Adam Laxalt – who didn’t have to face a credible primary challenger in the governor’s race – has said he disagreed with Sandoval’s decision to expand Medicaid but that he will not try to roll it back. “We’re a number of years into this system,” he told the Las Vegas Review-Journal earlier this year. “I think the important part for the coming years is to make sure we can pay for all of it.”

In Michigan, Attorney General Bill Schuette has attacked Lt. Gov. Brian Calley, his opponent in the Aug. 7 primary, for supporting Medicaid expansion. A narrator says in one commercial, “Calley brought Obamacare to Michigan.”

DeWine insists that his new position is not a flip-flop. His allies note that he was always careful with his language. He often said, for instance, that Medicaid “will not exist as we know it.” DeWine argues that calling for a work requirement and incentives for people to be healthy means that the system would be more accountable and sustainable. Many Republicans who have come to embrace Medicaid expansion cite the work requirement as a reason.

A veteran Republican operative in Ohio explained that “the messaging shift is a nod to Medicaid being a popular program” and added that “the work requirement piece is popular with the base.” He told me that Medicaid is inextricably linked to combating the opioid epidemic, so embracing the expansion four months before the election might help blunt attacks on that front in the fall. “DeWine is a practical guy,” the operative said, speaking on the condition of anonymity to more freely discuss the dynamics of the race. “He’s not a fire-breathing ideologue.”

A federal judge ruled the Friday before last that the Trump administration acted in an “arbitrary and capricious” manner when it allowed Kentucky to become the first state in the country to impose work requirements on Medicaid beneficiaries. The decision by U.S. District Judge James Boasberg sent the state program back to the federal Department of Health and Human Services. Since giving Kentucky Gov. Matt Bevin, a Republican, the green light in January, the Trump administration has also given permission to Indiana, Arkansas and New Hampshire to add work requirements. Several states, including Virginia, are putting together similar plans. But there is uncertainty now about whether all, or any, of these will hold up when challenged in court.