Democrats recently notched big gubernatorial wins in deep red Louisiana and Kentucky, and they took full control of the Virginia state legislature — all of which were driven in no small part by bruising local debates over the Medicaid expansion.

Now Democrats are hoping that this momentum for the Medicaid expansion, combined with the growing popularity of the proposal even in Republican territory, could finally produce a breakthrough that they’ve long coveted: in still-reddish North Carolina.

And if that doesn’t happen, they believe they can make North Carolina Republicans pay a big price for it.

Democratic Gov. Roy Cooper, who faces North Carolina voters next year, is planning to make the Medicaid expansion a key feature of his reelection campaign, according to political consultant Morgan Jackson, who works for the governor.

“This is an issue that 60 to 70 percent support, and it would save lives in North Carolina and help the economy,” Jackson told me. “You can guarantee that he’ll be talking about it.”

Democrats expect Cooper will face Republican Lt. Gov. Dan Forest, who opposes the Medicaid expansion. And they have good reason to believe this could be a potent issue in a gubernatorial race: The Democrats who won gubernatorial contests in Louisiana and Kentucky stressed the expansion in their own states, and the pollster for the Louisiana governor told this blog that it was the single most important issue.

“Forest has spent the last two years standing in the way of the Medicaid expansion,” Jackson continued. “That is absolutely something we’ll be highlighting.”

What seems to be happening in numerous red states is a combination of factors: While many GOP lawmakers in thrall to national right-wing messaging remain ideologically dug in against the Affordable Care Act, anger over it has receded in the rearview mirror for many ordinary red-state voters, and it’s become increasingly accepted even in red America.

Meanwhile, the basic logic of the Medicaid expansion — in which health coverage is extended to enormous numbers of poor and working people, even as the federal government pays 90 percent of the tab up front — is proving overwhelming.

This is particularly true in North Carolina, in part because the state is very rural, and as one health researcher recently observed, its rural areas are doing poorly by multiple health indicators.

The GOP-controlled state legislature has blocked the North Carolina Medicaid expansion ever since Cooper was elected in 2016. And Republicans will have to keep explaining why.

“Hospitals are losing money in rural areas, people are dying, and we need health-care jobs,” Jackson told me.

That creates another very interesting political dynamic, and it concerns the fact that Democrats are also hoping that GOP opposition to the Medicaid expansion helps them make gains in the state legislature.

Republicans have an eight-seat edge in the state Senate, which means Democrats have to flip five seats to take control — and Democrats have identified nine pick-up opportunities, according to the Democratic Legislative Campaign Committee (DLCC), which oversees state legislative races.

Republicans have a 10-seat edge in the state House of Representatives, so Democrats need to flip six seats to take control — and Democrats have identified 10 flip opportunities, according to the DLCC.

Democrats caution that these numbers are fluid, and taking control of either could prove extremely difficult. But there’s a test looming here. Of the seats Democrats are targeting, three state Senate seats and four state House seats are in rural districts, the DLCC says. The remainder are in suburbs.

It’s been widely noted, of course, that recent Democratic gains everywhere have been driven by big swings in the suburbs. But Democrats have a chance here to show that the Medicaid expansion can produce gains in rural areas as well.

“Democrats in the legislature will be running in 2020 on keeping rural hospitals open, saving lives and infusing millions in federal tax dollars into the economy,” Jackson said. “That’s a win-win in rural areas.”

Democrats, of course, still retain an outside hope that Republicans might buckle on the issue in advance of the election, and work toward a deal on expanding Medicaid. “Will they be politically smart, or let their ideology get in the way?” Jackson asked.

There’s another big reason this matters. For all the breakthroughs the Medicaid expansion has made in red states of late (37 states in total have now expanded it), it has still not gotten past GOP opposition in some very big ones — like Texas, Florida, and, yes, North Carolina. That remains a major obstacle to progress.

Indeed, the Kaiser Family Foundation estimates that if North Carolina expanded Medicaid, nearly 400,000 uninsured childless adults would become eligible for coverage. So getting it through here would be a big step forward.

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