After six long years of legislative inaction on closing the Medicaid coverage gap, the Virginia legislature voted this week to expand Medicaid. This is a hard-fought win and a life-changing development for the people of Virginia, 400,000 of whom are on the verge of gaining access to affordable health coverage. And, since Virginia is the first state to expand Medicaid through regular legislative order since Trump was elected into office (in fact, it’s the first state to do so since Montana expanded back in 2015), it is an early indicator of a new wave of momentum towards closing the coverage gap in the holdout states. What can these remaining states learn from Virginia’s long and winding road to expansion?

First and foremost, elections matter.

In November, voters in Virginia turned their off-cycle election into a referendum in support of Medicaid. They surprised analysts by ousting over a dozen Republican incumbents in the Virginia House of Delegates who had been instrumental in blocking the state from closing the coverage gap. Although Republicans maintained a slim margin in both the state Senate and House, a number of GOP legislators decided they didn’t want to be next in line to lose their jobs over this issue, and dropped their opposition to expansion, creating a legislative path forward for expansion in Virginia.

Second, advocacy doesn’t always produce immediate results – but steady, smart base building over time makes a difference.

The Health Care for All Virginians coalition (HAV) had kept up a steady drumbeat about the urgency of expansion since 2014 – even when efforts to expand in the state seemed futile. This week’s win built on the foundation they laid over several years. For example, in February, a key delegate from Southwest Virginia, GOP Delegate Terry Kilgore, came out in favor of expansion and ultimately helped bring other Republicans along to move Medicaid expansion through the House. This pivotal moment in the campaign was made possible by years of organizing in his district, where HAV coalition member Virginia Organizing has had a chapter for 23 years. Their deep roots in the district allowed them to engage with Del. Kilgore over a closed in-district hospital over the past 3 years, and educate him about how Medicaid expansion could have helped that hospital. Since the 2017 elections, advocates in the state ramped up their activities in his district, organizing dozens of members calling into his office, placing five letters to the editor in his district, holding a vigil in district that generated earned media, and bringing his constituents to meet with him in Richmond. Del. Kilgore’s eventual support for expansion, and this week’s win, was a culmination of years’ worth of advocacy.

Finally, Medicaid’s star is rising.

Medicaid expansion emerged from 2017’s ACA repeal debate as one of the most popular components of the law. And poll after poll after poll remind us that the public – including conservative-leaning voters – deeply support Medicaid and Medicaid expansion. How many more lawmakers need to lose their seats before they start listening to what their constituents want? In explaining his newfound support for Medicaid expansion, Senator Ben Chafin referred to the suffering hospitals and constituents in his rural district: “I came to the conclusion that no just wasn’t the answer anymore.”  It’s time policymakers across the country take heed. When it comes to addressing the needs of the millions of low-income families caught in the coverage gap, no just isn’t the answer anymore.