(OKLAHOMA CITY, Ok.) — In just under two weeks, the state of Oklahoma took part in two pandemic-related milestones, the first of which was hosting President Donald Trump’s campaign relaunch in the midst of the COVID-19 crisis.

The second milestone: On Tuesday, Oklahoma become the first state to expand Medicaid coverage under the Affordable Care Act since the onset of the pandemic.

The move was approved by a narrow majority of voters.

The ballot measure, referred to as State Question 802, passed with a slim 50.5% majority vote, and is now expected to expand coverage to more than 200,000 lower-income Oklahomans through a state constitutional amendment. The measure mandates that certain low income adults are able to qualify for health care coverage, and aims to prevent subsequent legislation from making it more difficult for them to obtain health insurance through the Affordable Care Act.

Although the initiative began before COVID-19 spread across the country, Tuesday’s decision brought a new level of significance to the Sooner State given its steady increase of reported coronavirus cases over the last several months. As of Wednesday, the Oklahoma State Department of Health reported more than 14,000 cases across the state.

“We protected State Question 802 in the constitution so that we could keep it out of the hands of politicians and special interests — so the language is pretty clear they have to expand Medicaid and the legislature has to fund it,” Amber England, campaign manager of the “Yes on 802 Oklahomans Decide Healthcare” initiative, told reporters during a teleconference Wednesday.

According to England, the passage of the measure would bring more than $1 billion in additional federal funds back to the state and would help “save rural hospitals.”

In a statement issued to ABC News Wednesday, Oklahoma Governor Kevin Stitt said the passage of State Question 802 tasked state legislators with “the difficult job of deciding where we will find an estimated $200 million in funding to support this constitutional mandate.”

Stitt, who has long opposed the move, said the state is looking at a $1 billion deficit for the upcoming year and said his options going forward include raising taxes or cutting “funding to core services, such as education, roads and bridges or public safety.”

England pushed back on the governor’s assessment, saying that while she’s “certain there will be a robust conversation” regarding the implementation of the amendment, the change will have to happen.

“We have a mandate from a majority of Oklahoma voters that says, ‘We want more health care, not less,"” she said.

According to analysis from the Kaiser Family Foundation, similar efforts to expand Medicaid through ballot initiatives have taken place in a handful of other states including Maine, Idaho, Nebraska and Utah over the last few years. Thirty-seven states and the District of Columbia have adopted Medicaid expansion, while 13 states have not, according to the non-profit foundation.

Missouri is currently one of the states that has yet to expand coverage, but the potential for change could be on the horizon following Gov. Mike Parson’s announcement earlier this year that Missourians would vote on the Medicaid expansion question as a part of the state’s August 4 primary election.

The possibility of another red-state shift three months before the November election could further fuel the Trump administration’s rhetoric against the Affordable Care Act. While Trump did not mention his predecessor’s signature policy during his June 20 campaign rally in Tulsa, Tuesday’s vote in Oklahoma served up a political rebuke of the current administration’s attempts to repeal the government-backed health insurance program while the country grapples with a pandemic.

“It’s very bad health care,” Trump said of the Affordable Care Act in May. “What we want to do is terminate it and give great health care.”

To date, the Trump administration has not offered up an alternative to the to the health care policy. In a June 2019 interview with ABC News, Trump promised to put forth a new plan that he said would “be less expensive than Obamacare by a lot.” At the time, Trump said his administration would have a proposal “in about two months, maybe less” but no plan was ever announced.

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