Kentucky voters on Tuesday elected just the second Republican in four decades to hold the governor's office, in a race that hinged largely on President Barack Obama's signature legislation, the Affordable Care Act.
The result was a potentially troubling sign for Democrats ahead of next year's presidential election and represented a big win for the GOP as it continues to consolidate political power across the South.
Democrats also were thumped in Virginia, where they made a big push to win a majority in one chamber of the state Legislature.
The governor's race in Kentucky was the highest-profile contest in Tuesday's off-year elections.
The only other gubernatorial campaign was in Mississippi, where Republican Gov. Phil Bryant won re-election.
Elsewhere, Ohio voters rejected an initiative that sought to legalize the recreational and medicinal use of marijuana, and Houston voters defeated an ordinance that would have established nondiscrimination protections for gay and transgender people in the city.
In Kentucky, Republican businessman Matt Bevin had waged a campaign to scale back the state's Medicaid expansion made possible under the federal health-care overhaul.
About 400,000 lower-income people who gained health coverage under the expansion could be affected.
The Republican also played up his support for Kim Davis, the Rowan County clerk jailed for refusing to issue marriage licenses to same-sex couples.
His Democratic opponent, two-term Attorney General Jack Conway, embraced Obama's health-care reforms, saying hundreds of thousands of residents could lose access to taxpayer-funded insurance if Bevin won.
Around the country, several high-profile ballot initiatives tested voter preferences on school funding, marijuana, gay and lesbian rights and the sharing economy.
Despite the relatively low number of races, the results could be a bellwether of sentiment ahead of next year's presidential elections.
In Virginia, a swing state, Democrats failed in an expensive bid to take control of the state Senate and empower Democratic Gov. Terry McAuliffe in negotiations with Republicans who control the state House.
The governor's race in Mississippi was overshadowed by a fight over a constitutional amendment that would allow people to sue the state to increase funding for public schools.
Critics say it would take budget decisions away from Mississippi lawmakers and give the courts too much power.
The Legislature has put forward its own ballot measure that would prohibit "judicial enforcement" of school funding.
The outcome could prompt similar efforts in other states where education remains a key challenge for lawmakers as they look to balance budgets with tax revenue that has yet to rebound to pre-recession levels.
In Houston, the nation's fourth-largest city, efforts to secure non-discrimination protections for gay and transgender people failed.
Now same-sex marriage is legal, such laws have become a priority for gay, lesbian, bisexual and transgender groups.
Opponents, including a coalition of conservative pastors, said the measure would have infringed on their religious beliefs.
Houston voters also were choosing from among 13 candidates to replace outgoing Mayor Annise Parker.
It was one of more than 300 mayoral races happening across the country.
San Francisco voters were deciding a citizen-backed initiative to restrict the operations of Airbnb, the room-rental site, and a $310 million bond package for affordable housing.
In Washington state, a proposal backed by Microsoft co-founder Paul Allen would add state penalties for anyone who imports certain animal products for commercial purposes, such as elephant ivory or rhino horns.
And Colorado voters decided to let the state keep $66 million in tax revenue generated from the sale of recreational marijuana.
An existing state law requires excess tax revenue to be returned to taxpayers, but on Tuesday voters agreed to make an exception with the marijuana revenue and direct it instead toward public education and drug-prevention programs.
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