It's never too early to start thinking about 2018. And while a lot of the focus so far has been on the House, a handful of hotly contested gubernatorial races could have higher stakes for health care — specifically, for the Affordable Care Act's Medicaid expansion.

2018 elections: A raft of open governors' races next year will give Democrats a chance to replace some of the most stridently anti-expansion governors in the country — and, if they win even a few of those races, the chance to cover millions of currently uninsured people even as the Trump administration drags its heels on so much of the ACA.

• 15 non-expansion states will hold gubernatorial elections this year or in 2018. Ten of those will be open seats.
• Democrats won't win all of those races. But several of their best political opportunities are in the states where Medicaid expansion would cover the most people.
• One of the biggest battlegrounds: Florida, where Gov. Rick Scott will be term-limited next year. The Cook Political Report considers Florida a toss-up. And if Scott's successor is more amenable to the Medicaid expansion, nearly 800,000 Floridians could gain coverage, according to the Kaiser Family Foundation's estimates.
• Maine Gov. Paul LePage — one of the ACA's loudest critics — is also leaving office, and one of the expansion's biggest defenders — Sen. Susan Collins — might run to replace him.
• Virginia's state legislature has previously come up just a few votes shy of adopting the expansion, which would cover some 225,000 people.

Why it matters: There's not much the Trump administration could do to stop more states from signing on to the Medicaid expansion, especially if those states don't seek waivers from certain structural rules as part of the process. And that means Democrats have a real chance to build on the ACA's coverage gains, even under a hostile administration — if they can get their act together at the state level.

Technically, the Children's Health Insurance Program has to be reauthorized by Sept. 30 — which is cutting it pretty close, since the Senate Finance Committee is holding its first hearing in September. But of course, Congress only acts when it's up against the "real deadline." The real CHIP deadline may be later than Sept. 30 — but it's also earlier than Congress thinks.

House Republicans noted that according to projections from the Medicaid and CHIP Payment and Access Commission (MACPAC), states won't actually start to run out of CHIP funds until December at the earliest. But the National Academy for State Health Policy points out that there's a whole range of actions states have to take before then if they don't have a guarantee that the federal funds will continue.

Some of the biggest ones, per NASHP senior program director Maureen Hensley-Quinn:

• Warning families that they may not be able to renew their CHIP coverage. Colorado has already done this.
• Deciding whether to renew contracts to support their programs, including managed care plans, vendors, and call centers.
• Re-evaluating the eligibility of kids in the program, in case they have to be switched to Medicaid or ACA coverage.
• Making plans to make sure medical care isn't disrupted for children with chronic conditions.

The bottom line: Republicans and Democrats insist they can keep the CHIP reauthorization bill free of controversial amendments that would make it harder to pass quickly. We'll see if they can pull it off.

The Senate passed the reauthorization of the FDA user fees yesterday by a lopsided vote of 94-1. Who was the one? It was Bernie Sanders, returning to his pre-presidential campaign form as the guy who doesn't care if the army is with him or not.

Why did Sanders vote against it? Because the FDA bill "does nothing to lower drug prices and is a giveaway to the pharmaceutical industry," per his spokesman, Josh Miller-Lewis. (One provision Republican Sen. Susan Collins did cite as a measure against high drug prices: It would require the FDA to speed up the reviews of generic drug applications in markets where there's not a lot of competition.)

What's next: Because the Senate cleared the House version of the FDA bill, it can go straight to Trump's desk. He's expected to sign it into law.

Bob Herman told you about the massive Medicare hospital payment rule in yesterday's Vitals, and he kept reading and found more stuff in it. There are some clear lobbying victories — like a smaller cut for a heart device payment code than the Centers for Medicare and Medicaid Services had originally proposed, bigger payments for total ankle replacements, and add-on payments for two heart valve devices.

Read Bob's story to find out what else the lobbyists got for their hard work.

One other big health care vote happened yesterday: The Senate approved a "right to try" bill that would let terminally ill patients use treatments that haven't been approved by the FDA. The House hasn't passed its own version of the bill, which has to happen before Trump can sign it into law. But Senate Republicans are hoping to convince the House to pass the Senate bill, sponsored by Republican Sen. Ron Johnson and Democratic Sen. Joe Donnelly.

The back story: 37 states have already approved laws based on the proposal, which has been promoted by the libertarian Goldwater Institute. The argument from supporters is pretty much what you'd expect: Dying people have nothing to lose by trying the treatments they want. The danger, critics say, is that unapproved treatments could do them more harm than good.

For more, Bloomberg's Anna Edney has a good rundown here.

The Senate confirmed Jerome Adams, Indiana's state health commissioner, as surgeon general yesterday as part of its massive nominations package. (Trump ousted the previous surgeon general, Vivek Murthy, in April.)

Here's the quick run-down of what you need to know about him, per Caitlin Owens:

Adams joins the small group of appointees with Indiana connections to Vice President Mike Pence. Pence appointed him as health commissioner in 2014, when Pence was then governor of Indiana. Adams also worked on the state Medicaid program with Seema Verma, now the head of the Centers for Medicare and Medicaid Services.Notably, he helped establish a needle exchange program in 2015, a response to the outbreak of HIV from sharing needles, USA Today reported.At his confirmation hearing this week, Adams treaded carefully around the issue of gun control, saying that gun violence is separate from guns, per STAT. "Guns and gun owners aren't inherently a public health problem, but the violence that results absolutely is," he said. (Murthy insisted that gun violence is a public health issue.)He also said he'd put science over politics, which Democratic senators brought up in response to comments by the president and administration officials about issues like autism and medication-assisted treatment of opioid addiction.