Republicans’ strong showing in this week’s mid-term elections opens the door to more calls to repeal President Obama’s signature law, the Affordable Care Act.

And while that is all but impossible given the balance of power in the U.S. Senate, victories in Washington and at the state level could usher in other healthcare changes.

A prime target?

The GOP could look to tweak Medicaid, the healthcare program primarily for low-income people.

To understand what reforms the GOP may propose, first understand this: lots of Republicans oppose Medicaid expansion under the Affordable Care Act on philosophical grounds.

“Medicaid was a program designed for the truly needy, and Obamacare makes it an income-based, and goes much higher for working age able-bodied adults,” says Josh Archambault, with the Foundation for Government Accountability.

Archambault says conservatives tend to think able-bodied adults shouldn’t get government-funded healthcare.

So states—including ones with new GOP governors like Illinois and Massachusetts—may pitch Medicaid reforms that introduce monthly premiums and/or co-pays.

Robin Rudowitz with the Kaiser Family Foundation expects to hear lots of proposals in the coming months.

“[Secretary Sylvia Burwell] spoke and said that she was willing and interested in working with states that wanted to expand. So I think that we will see alternative proposals. How far they go, I think that’s a question,” she says.

Until now, federal health officials have blocked reforms that would make it hard for people to get healthcare, like mandatory work requirements.

That could ultimately mean GOP’s Medicaid worldview is on a collision course with the Administration’s Medicaid philosophy.