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Deeply conservative Oklahoma narrowly approved a ballot initiative Tuesday to expand Medicaid to nearly 200,000 low-income adults, the first state to do so in the midst of the coronavirus pandemic.

The vote to expand the Affordable Care Acts reach once again put voters, many of them conservative, at odds with Republican leaders, who have worked to block it or invalidate it. Five states Maine, Utah, Idaho, Nebraska, and now Oklahoma have used ballot initiatives to expand Medicaid after their Republican governors refused to do so.

Oklahoma pushed the G.O.P. over a notable threshold: Most congressional Republicans now represent Medicaid-expansion states. The vote also came at a striking moment, less than a week after the Trump administration asked the Supreme Court to overturn the entirety of Obamacare including Medicaid expansion.

What we saw last night was Medicaid expansion triumph over party and ideology, said Jonathan Schleifer, executive director of the Fairness Project, which has helped organize all the Medicaid votes. Oklahoma voted for Medicaid expansion even as Trump is doubling down on repeal.

Medicaid expansion could spread further into Republican-controlled states this year, as they weigh how to cover the many unemployed Americans expected to lose health insurance along with their jobs. Missouri voters will decide on a ballot initiative at the states August primary. If it passes, it will expand Obamacare coverage to 217,000 low-income people.

Some Wyoming legislators recently took a fresh look at the program, too, as they watched job losses mount. Ive voted against it about 10 times, never voted for it, said the states House speaker, Steve Harshman, a Republican. Now Im thinking of our work force. Were a mineral and oil kind of state. Thats a lot of able-bodied adults in a lot of industries who will probably need some coverage.

Mr. Harshman voted in May to have a legislative committee study the topic, but he does not expect any action until the bodys next session begins in January.

Medicaid expansion has proved an especially resilient part of the health care law, despite early challenges. The program, which provides coverage to Americans earning less than 133 percent of the federal poverty line (about $16,970 for an individual), was initially meant to serve all 50 states.

But in a 2012 ruling, the Supreme Court declared that states could decline to participate. The program began in 2014 with about half of the states, mostly run by Democratic governors.

That figure has grown to 37 states and the District of Columbia, as more Republican-controlled states have signed on. Many academic studies have found that the program increases enrollees access to medical care. A more limited body of research shows that the program also reduces mortality rates.

The program still faces threats, most significantly the Trump administration lawsuit to overturn the health law. The Department of Justice, alongside a coalition of 20 Republican-controlled states, submitted briefs to the Supreme Court last week arguing that the recent repeal of the individual mandate, which required all Americans to carry health coverage or pay a fine, made the entire law unconstitutional.

President Trump has found strong support in Oklahoma; he took 65 percent of the vote there in 2016 in a 36-point victory, and recently held a campaign rally in Tulsa, his first since the start of the pandemic.

Still, voters there broke with him on this issue, albeit by the margin of one percentage point. The ballot initiative drew 30,000 more voters than the states Senate primaries, suggesting that some Oklahomans came out specifically to support the insurance expansion.

Oklahoma is an awfully red state, said Adam Searing, an associate professor at Georgetown University who has tracked the states ballot effort. Its very conservative, very rural. To have it pass there is quite significant.

Oklahomas Republican leadership had opposed Medicaid expansion and initially offered more limited alternatives. Gov. Kevin Stitt outlined a program in January in which new low-income enrollees would pay modest premiums and be required to work to gain coverage.

He went on to veto that program, after the legislature secured its funding.

Oklahoma was also the first state to ask the Trump administration for permission to convert its Medicaid program to block grant funding, an idea strongly pushed by Mr. Trumps health appointees. The state would receive a lump-sum payment from the federal government to run the program with additional flexibility. Opponents of that proposal worry that such a funding formula could struggle to keep up with increased enrollment in an economic downturn.

Oklahoma submitted its application in April, and the Trump administration had not issued a decision before the Tuesday vote.

Oklahomas ballot initiative is notable in being the first to add the Medicaid expansion to the states Constitution. That will make it hard for Governor Stitt and the Republican-controlled legislature to tinker with or block the program, as other governors have sought to do in the wake of successful ballot initiatives. Most notably, when Paul LePage was governor of Maine, he declared he would go to jail before implementing the states Medicaid ballot initiative. The situation was resolved when a Democratic governor was elected and set up the coverage expansion.

In Oklahoma, ballot organizers can pursue either statutory or constitutional initiatives. The latter have more staying power but also require gathering twice as many signatures. Amber England, who led the ballot effort, felt the additional work was worth it.

If were going to ask people to get clipboards and pens, and gather signatures, we want to make the policy as strong as possible, she said. It was important that we protect Oklahomans access to health with the Constitution. We didnt want politicians to be able to take that right away.

Missouri will be the next state to vote on Medicaid expansion, in its Aug. 4 primary. The state is a party to the Trump administrations case against Obamacare. Gov. Michael Parson, a Republican, has publicly opposed that ballot initiative, which he argues is too costly in the midst of an economic downturn. Missouri would need to cover 10 percent of new Medicaid enrollees bills, with the federal government paying the other 90 percent.

I dont think its the time to be expanding anything in the state of Missouri right now, Mr. Parson told a local television station in early May. Theres absolutely not going to be any extra money whatsoever.

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Republican Leaders Want to End Obamacare. Their Voters Are Expanding It. - The New York Times