Tomorrow is election day in many states, counties, and cities in the U.S., and in some places the results really are a matter of life and death for many people. Once again John Oliver performs a public service by explaining why:

In brief, the Affordable Care Act was intended to cover as many people as possible by doing two things: First, those above the poverty level who didn’t already have health insurance through employment or Medicare would be able to buy it on an exchange, with most getting a subsidy to make it affordable. Second, those with very low income would qualify for Medicaid. (As a practical matter there is some overlap between the two, not least because people’s circumstances can change mid-year.)

Medicaid has long provided healthcare for low-income people in the United States, but different states have somewhat different criteria for Medicaid eligibility. Some covered only a subset of poor adults, mainly those with dependent children or who totally impoverished elderly or severely disabled long-term residents of nursing homes.

This variation has to do with the way Medicaid operates, as a joint federal-state project. As with highway and education funding, Medicaid is voluntary for the states, but if the states accept the funds, they have to follow certain conditions. In practice, all states implement Medicaid. The Affordable Care Act requires states to expand Medicaid to cover the great majority of poor adults and children living legally in the United States. To make this more palatable, federal funds cover the entire costs for three years, declining to 90 percent of costs after the year 2020. This is an even better deal than it sounds. Keep in mind that many, many hospitals in the U.S. are operated by cities, counties, or state-supported institutions such as universities. More insured people means fewer hospital bills that go unpaid.

But the Supreme Court, in a ruling with questionable constitutional justification, decreed that states can choose between the new Medicaid rules and the older ones. Many states under Republican control, especially in the South, rejected Medicaid expansion for purely political reasons, even though this has ended up costing them (not to mention hospitals and many healthcare providers) a lot of money.

Why? I went into that in an earlier post you can read here. In brief, many conservative strategists cynically argued that if a Democratic healthcare reform effort succeeded, it would be very bad news for Republican electoral prospects. In 2008 the CATO’s Michael Cannon published an article titled, “Blocking Obama’s Health Plan Is Key to GOP’s Survival.” James Pethokoukis of the American Enterprise Institute declared healthcare reform would “kill conservatism” and quoted a “scary serious” unnamed GOP strategist who had said to him, “Let me tell you something, if Democrats take the White House and pass a big-government healthcare plan, that’s it. Game over.” A year later, after Obama’s election and with healthcare reform advancing in Congress, Senator Orrin Hatch (R-Utah) warned that if healthcare reform proved successful, “you’re going to have a very rough time having a two-party system in this country, because almost everybody’s going to say, ‘All we ever were, all we ever are, all we ever hope to be depends on the Democratic Party.'”

Note that the fear isn’t that healthcare reform would prove unsuccessful; quite the opposite: The better it works, the worse it makes its opponents look. This is why Republican continue to treat Obamacare not as a partial success with problems that ought to be fixed but as a total catastrophe, which is objectively just nonsense. It’s why right-wing pundits blame healthcare or health insurance problems on the Affordable Care Act no matter whether there’s a connection or not.

And it’s also the most likely explanation why right-wing leaders of a lot of states continue to block Medicaid expansion despite the fact that doing so harms their states both economically and in terms of helping their neediest citizens get necessary medical care.

Update 2015 November 4: The state with the most to lose from this election is possibly Kentucky, which has one of he best insurance exchange websites in the country and had introduced Medicaid expansion, leading to a huge reduction in the number of uninsured persons. Unfortunately, an extreme Tea-Party type was elected governor, and during the campaign he had promised to reverse the Medicaid expansion (canceling health insurance for thousands of people who can’t afford an alternative) and do away with Kynect. Some reports are indicating that the governor-elect has had second thoughts in the face of dire warnings, and he will seek simply to do away with Kynect and have people buy insurance through the federal exchange, and in addition retain most or all of the Medicaid expansion with some tweaks. (The state can’t just cancel Medicaid expansion anyway; it has a contract with the federal government.)

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