It’s health care, stupid

This seems to be the big take-home message from voters in the mid-term election held yesterday, which bodes well for preserving gains from the Affordable Care Act and expanding coverage.   Health care was the number 1 issue for voters according to several exit polls, beating out immigration, the economy, and gun violence, among others, with voters strongly favoring Democrats as the party more likely to protect patients with pre-existing conditions.  Preserving the ACA’s protections for pre-existing conditions arguably may have been the single greatest contributor to Democrats taking control of the House of Representatives from Republicans, gaining at least 30 seats. 

Yet Republicans not only kept control of the Senate, they also expanded the number of Senate seats they control, adding at least 3 seats to be held by members with strongly conservative views. This raises questions about how much of the electorate’s desire for Congress to act to make health care more affordable to them and their families will translate into action in Congress; preserving existing patient protections may be the most likely outcome.

The story at the state level is very different: more states seem poised to expand Medicaid coverage; yet on other health care issues, like women’s access to reproductive services or reducing gun violence, the prospects at the state level are more mixed.

Here’s my take on five health care issues likely to be affected by the mid-term election results:

1.  Obamacare repeal and replace is dead. The Democratic-controlled House of Representatives will not allow legislation to advance to repeal, or repeal and replace, the Affordable Care Act. 

Except . . .Congress will have to do something to preserve protections for preexisting conditions, if the courts ultimately rule in favor of a case brought by 20 GOP-led states and supported by the Trump administration that seeks to have the ACA’s protections for pre-existing conditions ruled unconstitutional.  A decision by a conservative Texas judge is imminent and should he rule for the plaintiffs, as many expect, it will assuredly be appealed to the higher courts; it may be up to the Supreme Court to ultimately decide.  Stripping pre-existing condition protections via a court decry will be hugely unpopular with the electorate, and almost all of those elected yesterday promised to protect them (even when their own voting records suggest otherwise). However, it’s by no means certain that a Democratic House, Republican Senate, and President Trump could agree on a path forward to reinstate them.  The best outcome would be for the courts to find that the case has no merit and rule against the plaintiffs.

And . . . while there may be interest in both political parties to advance bills to make the ACA more affordable for those who are not eligible for premium subsidies because they earn too much to qualify, it is hard to see a path forward that could bridge the ideological divide between Republicans and Democrats.  House Democrats will also try to advance bills to overturn the administration’s decisions to allow sale of short-term plans that do not cover essential benefits, yet such bills likely would die in the Senate, or face a veto from the president.  States that have elected Democrats as governors and to the statehouses may pass legislation on their own to ban or regulate sale of short-term plans.

2.  More low-income people will gain coverage from Medicaid expansion, upwards of half a million of them.  Voters approved Medicaid expansion via referenda in three GOP-leaning states: Idaho, Nebraska, and Utah. The election results in three other states, Maine, Wisconsin, and Kansas, also bode well for expansion.  Montana voters, however, voted down a referendum to continue to fund their version of Medicaid expansion via higher tobacco taxes, potentially placing coverage for their residents at risk.  Republicans elected or re-elected to the governorships in other states are unlikely to expand Medicaid, and/or will seek to include work requirements that may make it more difficult for people to qualify.

3.  Prospects for policies to address the high cost of prescription drugs may advance at both the state and federal levels.  In his initial remarks today on the midterm elections, President Trump suggested that common-ground could be found with Congress and the Democrats on lowering the cost of prescription drugs. Many Democrats newly elected to the governorships and state legislative seats favor policies to require transparency in drug pricing.

4.  Common-sense policies to reduce gun violence may be advanced in additional states, as voters elected candidates to governorships and legislatures who favor such policies; yet in other states, voters elected or re-elected candidates opposed to such policies.  Voters in Washington state approved a referendum to advance restrictions on firearms. NBC’s exit poll found that 60% of those who casted votes favored stricter gun control policies, including 46 percent of gun owners compared to 76% of those who don’t own firearms; just one-in-ten ranked it as the most important issue facing the country. Democrats are likely to advance gun violence policies in the House, yet it is unlikely that a more conservative Senate and the Trump administration will accept them.  On the other hand, the House will almost certainly reject concealed carry reciprocity, should it be taken up next year by the Senate.  (In the current Congress, such legislation passed the GOP-controlled House, but was not taken up by Senate).

5.  It’s a mixed bag for women’s health.  The House of Representative will not advance or accept legislation to defund Planned Parenthood and other women’s health clinics.  It may try to advance bills to overturn the administration’s efforts to allow broad “conscience exemptions” to contraception coverage, yet it’s hard to imagine those being accepted by the Senate.  With more states under partial or complete Democratic control (governors and statehouses), bills to ensure women’s access to reproductive services may fare better in those states than in the past; voters in several other states yesterday advanced measures to greatly restrict access to such services.  For many women, access to necessary services will depend on where they live. 

There are many other issues that are less partisan and may find common-ground in the new Congress, including improvements in the Medicare Quality Payment Program, payment for primary and comprehensive care, reducing barriers to chronic care, addressing the opioids epidemic, and reducing administrative tasks imposed on physicians and patients.

One thing is sure: voters yesterday ranked health care as the most important issue behind their votes, and politicians who ignore them, or let partisan divisions lead to inaction, will do so at their own risk.