Health care is on the ballot this year, in more ways than voters may realize.

Full repeal of the Affordable Care Act remains a very real possibility if Republicans get through the midterm elections with their congressional majorities intact. But even if the law stays on the books, its future will depend heavily on who wields power at the state level as governors, insurance commissioners and members of state legislatures.

These officials have always had a lot to say about the ACAs implementation, although they rarely get the attention they deserve. Now they have even more influence, thanks to the ways that President Donald Trump and his allies have battered the law over the last 18 months.

The most recent change came from Washington early this month, when the Trump administration made it easier for people to buy short-term insurance that leaves out key benefits like mental health and prescriptions and isnt available to people with pre-existing conditions. The plans hare tantalizingly low premiums, but they can expose beneficiaries to crushing medical costs all while driving up the price of more comprehensive coverage.

Short-term policies wont be available everywhere, because states can restrict or even prohibit them. Some have done so already. But whether more follow will hinge, in part, on who is making the decisions come 2019.

The current state of play for health care is a reminder of one way that the GOPs war on Obamacare has made headway by giving states more control so that access to health care in places like Georgia looks more and more different than it does in California.

It wasnt supposed to be this way, at least not exactly. The idea of the ACA was to make sure all Americans, in all states, could get health insurance, partly by creating new, subsidized market of regulated private plans and partly by offering Medicaid to all Americans living below or just above the poverty line.

But a 2012 Supreme Court decision made it easy for state officials to reject the Medicaid expansion and GOP leaders in 17 states have done just that, even though the federal government picks up nearly all of the expansions cost. (Its 18 states if you include Maine Gov. Paul LePage , who refuses to carry out an expansion the states voters approved by ballot initiative.) Republican officials in a similar, overlapping list of states have done their best to undermine the private insurance reforms.

In Florida , a lieutenant to Rick Scott, the governor now running for U.S. Senate, blocked enrollment counselors from holding events in state buildings. In Georgia, insurance commissioner Ralph Hudgens came right out and said he and his colleagues were doing everything in our power to be an obstructionist. In Iowa and Tennessee , state officials made it easy for people to stay out of the newly reformed markets and enroll, instead, in plans that dont comply with the ACAs standards for benefits and open enrollment.

That last part is important because it has directly undermined how the new system is supposed to work. Insurers need healthy people paying into the system so that theres enough money to cover the high medical bills of the people with serious health problems.

The ACA includes provisions to make that happen, including tax credits (which make insurance cheaper) and the individual mandate (which penalizes people who dont get comprehensive coverage). But in states where officials have not done their part, enrollment among healthy people has lagged and insurers have jacked up premiums in response making coverage flat-out unaffordable for some of the people who dont qualify for tax assistance.

Things are likely to get worse, thanks to what Republicans in Washington have done since Trump took over. They have passed a tax cut that effectively eliminates the individual mandate penalty . They have slashed funding for enrollment outreach. Now, with this latest regulatory change, they have made it easier for people to purchase and then hold onto short-term plans that dont comply with the ACAs standards.