Virginia dominated the political headlines last week, and with good reason: The state’s gubernatorial election handed a race-baiting Republican candidate a definitive loss and provided beleaguered Democrats some early hope for their chances in the 2018 midterms. But progressive victories weren’t limited to Virginia. Maine provided the week’s other big surprise when it voted overwhelmingly to expand Medicaid. The vote was a rebuke to the state’s Republican governor, Paul LePage; to Donald Trump, to whom LePage pays homage; and to the Republican Party itself, which has prioritized the destruction of the Affordable Care Act.

LePage, a longtime enemy of the welfare state, has promised to block the measure. This was to be expected: He has vetoed five bills to expand Medicaid during his seven years in office. LePage has shrunk MaineCare, the state’s Medicaid program, while his most recent budget proposes cutting $12 million from the General Assistance welfare fund. But since the expansion was approved in a referendum, his options are more limited now. As long as the state legislature finds a way to fund it, LePage must implement the policy. If LePage refuses to do, he will not only invite a lawsuit, but also drive the state deeper into misery.

It is no exaggeration to say that Mainers are dying as a result of the state’s negligent policies. In 2016, Adanya Lustig and Erin Rhoda of The Bangor Daily News reported that the state’s infant mortality rates are rising at rates that set it apart from the rest of the country. “Because Maine has a small number of babies, year-to-year death rates often fluctuate. But comparing averages of the infant mortality rate between 1995 and 2004 with 2005 and 2014 shows there was almost a one-point increase,” wrote Lustig and Rhoda. “Every other state lowered its infant mortality rate or kept it constant over this time.”

This rising infant mortality rate coincides with a raging uptick in overdose deaths. The Portland Press Herald’s Eric Russell reports that Maine now averages roughly one overdose death per day, with the numbers increasing dramatically every year. “From 2013 to 2014, Maine saw the third-highest increase in any state, 27 percent,” Russell writes. “Comparable state-by-state data has not been compiled for 2016 but the recent numbers for Maine, where deaths increased by another 39 percent, suggest the trend is worsening.” Those numbers indicate a major public health crisis, but LePage’s response so far has been to suggest that first responders charge anyone who requires multiple doses of Narcan, a drug that revives people dying from opioid overdose.

While these public health trends eat into the state’s younger generations, its overall population has declined. Already the oldest state in the country, Maine is now a place where more people die than are born. Its crisis is an existential one. In Medicaid, the state’s residents see a lifeline.

“Maine is in a tough place in a number of ways,” says Sara Gideon, Maine’s Democratic speaker of the House. “We have a really high number of elderly people as well as disabled people. We also have a really large number of low-income people or people living in deep poverty and poverty.”

The opioid epidemic has also gotten “out of our control,” she explains, adding, “If you talk to most people who are out there on the front lines fighting the opioid epidemic, they will tell you that the number one tool they feel would help us be successful is having access to Medicaid expansion.”

David Farmer, a spokesperson for Mainers for Health Care, says, “Our hospitals are struggling. We have hospitals that have stopped delivering babies. We have hospitals that are operating in the red and Medicaid expansion is critical to helping them stay open and ensuring that they can continue to provide services in their community.”

When LePage blocked legislation expanding Medicaid, activists and organizers went around him. It’s no small feat to collect the necessary signatures to put the proposal on the ballot, let alone drum up enough votes for it to win. Maine is a wilderness state, with one of longest coastlines of any state in the country. It has a clutch of inhabited islands, some of which can only be reached by ferry or air taxi. Dense woods isolate the northern tip of the state from its more urban, tourist-friendly down-east corridor. The typical partisan divisions don’t quite apply, either: The state is home to many unenrolled voters, meaning they are unaffiliated with either the Democratic or Republican parties.

That Medicaid expansion won at the ballot reflects a high level of grassroots support for the policy. “Maine voters are engaged, thoughtful, and knowledgeable. They expect to be talked to,” Farmer explains. “Over the course of the campaign, we knocked on more than 200,000 doors to have individual one-on-one conversations about the importance of health care and Medicaid expansion particularly.”

Genevieve Lysen, an organizer with the Maine People’s Alliance, says she knocked on 1,300 to 1,400 doors in Androscoggin County to campaign for Medicaid expansion and to recruit potential spokespeople. “The person that sticks out the most in my mind is a woman named Donna Wall who lives in a housing project called River Valley in Lewiston, Maine,” she recalls. “And she had just had her MaineCare cut by Governor LePage because her two twin autistic sons turned 18, though she still cares full time for them and for a 21-year-old autistic girl.”

To afford their health care in addition to her own, Wall works a paper route from midnight to four in the morning. She comes home, prepares the young adults in her care for a local program, then sleeps until two in the afternoon. Lysen says it’s the only time Wall gets to rest—and that in Maine, she isn’t an anomaly. “So often I found folks who had children that were between, like, 18 and 30 that they were still supporting in some way, whether they were still living in their home or they were helping them with finding work or they were taking care of them physically,” she explains. “It felt like one of the most common sense issues I’ve ever canvassed toward in my career.”

She adds that there was “negligible” pushback to the proposal: “It was just stunning to me. We would get back from canvasses and I’d look up at the tally sheets and see that 18 out of 18 conversations that somebody had were positive views.”

LePage is term-limited, but Maine’s broad support for Medicaid expansion could trouble any future political ambitions. It may also undermine LePage’s party: Maine Democrats like Gideon have been heading the charge for Medicaid expansion for years. Farmer says, “It’s a message that’s consistent with what we heard in the health care fight in Washington. People want more health care, not less. They want more people to have coverage. They want the system to be more fair. That’s what Medicaid expansion is all about.”

For now, state legislators are preparing to convene in January 2018, and they’ll then have 45 days to officially pass the expansion. Despite the fact that Republicans control the state Senate (Democrats control the House), the legislature has already approved the expansion enough times that there’s hope it will be able to finance the annual costs. After that, the LePage administration must create the rules necessary for Medicaid to reach Mainers who have demanded it.

Gideon emphatically rejects LePage’s contention that expansion will bankrupt the state. “Maine cannot afford not to do this,” she concludes. “We cannot afford to continue to reject federal funds that would actually give more people access to health care.”