Can a Divided Congress Fix Health Care?

The Kaiser Family Foundation’s latest tracking poll finds that costs and affordability are the health care issues Americans most want Congress to address — though the public remains highly skeptical that Democrats and Republicans can actually work together to do anything on health care.

The poll also finds that the favorability of the Affordable Care Act has risen to 53 percent and that 59 percent of people living in states that have not expanded Medicaid under the ACA want such an expansion.

Key Findings:

  • The November KFF Health Tracking Poll, conducted the week after the 2018 midterm election, finds a majority of the public wants the new Democratic majority in the U.S. House of Representatives to work with Republicans on legislation to address the major problems facing the country as well as conduct oversight of the Trump administration’s actions on policies such as health care. Yet, few Americans are “very confident” (6 percent) that Republicans and Democrats in Congress will be able to work on bipartisan legislation to address the health care issues facing the country.
  • The midterm elections brought Medicaid expansion to three additional states, bringing the total number of states that have expanded their Medicaid programs to cover more low-income uninsured adults to 37 (including Washington, D.C.). Those living in states that have not expanded their Medicaid programs continue to hold a favorable view of Medicaid expansion and most would like to see their state expand their Medicaid program. And as a possible indicator of how some other states may expand their Medicaid programs in the future, most of those living in a non-expansion state say that if their state government chooses not to expand, voters themselves should be able to decide if their state expands their Medicaid program.
  • The new Democratic majority in the House all but guarantees the Affordable Care Act (ACA) will remain the law of the land for at least the next two years. The most recent tracking poll finds a slight uptick – largely driven by Democrats – in the overall favorability of the law (53 percent) and many of the ACA’s provisions continue to be quite popular with a majority of the public. But the poll also finds the public is largely unaware about the law’s sixth open enrollment period, and four in ten 18-64 year olds who buy their own insurance or are currently uninsured say they will choose to go without coverage in 2019.

    Most Americans say it is “very important” to keep the ACA provisions barring insurers from denying coverage or charging more (62%) to people with pre-existing conditions, even after hearing that these may have increased costs for some healthy people

  • A divided Congress does not mean that the coming year will not see any changes to the country’s health care system. There is an impending lawsuit, Texas v. United States, which may end the ACA’s protections for people with pre-existing medical conditions as well as the Trump administration’s recent actions allowing employers to be exempt from covering the full cost of birth control for their employees if they oppose to it due to religious or moral reasons, which could lead to substantial changes to health coverage for many Americans. This month’s tracking poll examines the public’s support for these proposed changes and examines the malleability of these opinions.

The Public’s Priorities for Next Congress

With Democratic gains in the U.S. House of Representatives during the 2018 midterm election, Democrats and Republicans will split control of Congress next year. These results will mean that President Trump will have a divided Congress for the first time in his presidency. About half of the public (53 percent) say oversight of the Trump administration’s actions on policies such as health care, education, and the environment should be a “top priority” for House Democrats in the coming year. This is similar to the share (55 percent) who say that working to enact new laws to address the major problems facing the country should be a “top priority” for House Democrats in the coming year and substantially larger than the share who say investigating corruption within President Trump’s administration should be a “top priority” (36 percent).

Majority of The Public Say Working To Enact New Legislation And Oversight Are Top Priorities For Democrats

Figure 1: Majority of The Public Say Working To Enact New Legislation And Oversight Are Top Priorities For Democrats

Unsurprisingly, the share of partisans who say each of these should be a “top priority” for Democrats in the U.S. House of Representatives varies drastically; majorities of Democrats saying conducting oversight (77 percent), working to enact legislation (67 percent), and investigating corruption (58 percent) should all be top priorities for the coming year. A majority of independents (54 percent) say working to enact legislation should be a “top priority,” while less than half of Republicans say any of these – including working to enact legislation – should be “a top priority” for House Democrats.

Figure 2: Most Democrats Say New Legislation, Oversight, and Investigating Corruption Are Top Priorities For House Democrats

Figure 2: Most Democrats Say New Legislation, Oversight, and Investigating Corruption Are Top Priorities For House Democrats

Immigration and Health Care Top Public’s Priorities

Similar to the issues driving voters in the 2018 midterm elections, the most recent KFF Health Tracking Poll finds immigration and health care as the top issues the public want to see the next Congress act on in 2019 with the issues offered largely driven by party identification. Overall, about one-fifth of voters offer immigration or border security (21 percent) when asked to say in their own words the issue Congress should work on next year. This is similar to the share of the public who offer health care (20 percent) as the top issue they want to see the next Congress work on. Fewer offer gun control/legislation (8 percent), tax reform (4 percent), or education (4 percent) as the issues they want to see Congress act on in 2019.

Four times as many Republicans (41 percent) offer immigration/border security as the issue they would most like the next Congress to act on in 2019 as Democrats (10 percent). On the other hand, health care is the top issue for Democrats. One-fourth of Democrats (27 percent) say health care is the issue they would most like to see the next Congress act on, compared to 11 percent of Republicans who say the same. Independents are divided across the top two issues, with similar shares offering immigration/border security (22 percent) and health care (21 percent) as the issues they want to see Congress work on.

Table 1: Immigration and Health Care Top Public’s Priorities for Next Congress
Thinking about next year, which issue would you most like the next Congress to act on in 2019? (open-end) Total Democrats Independents Republicans
Immigration/Border security 21% 10% 22% 41%
Health care 20 27 21 11
Gun control/legislation 8 13 4 8
Tax reform 4 2 7 8
Education 4 7 2
Note: Only top five responses shown. Question asked of half sample.

When asked which health care issue they would most like to see the next Congress act on in 2019, more Americans offer issues around health care affordability and cost (19 percent) than other health care issues including the 2010 Affordable Care Act (ACA) (10 percent) or Medicare (6 percent). Health care affordability and cost are also the most frequently mentioned health care issues by Democrats (14 percent), independents (25 percent), and Republicans (17 percent). The ACA is the second most frequently mentioned health care issue among partisans, with Democrats saying they want to see Congress “protecting or improving the ACA” while Republicans say they want to see the next Congress “repealing the ACA.” Independents are divided on this issue, with similar shares saying they want to see Congress repealing and protecting the 2010 health care law.

Figure 3: Cost And Affordability Top Public’s Health Care Priorities For Next Congress

Figure 3: Cost And Affordability Top Public’s Health Care Priorities For Next Congress

While there appears to be consensus among the public on what health care issue they want to see Congress work on next year, not quite one-third are confident that Democrats and Republicans in Congress will be able to work together on bipartisan legislation to address the health care issues facing the country. In fact, seven in ten say they are either “not very confident” (34 percent) or “not at all confident” (35 percent) that Congress will be able to work on such bipartisan legislation, while fewer are confident, either “very confident” (six percent) or “somewhat confident” (24 percent), in Congress being able to work together.

Figure 4: Less Than One-Third Are Confident Congress Can Work Together To Address Health Care Issues Facing The Country

Figure 4: Less Than One-Third Are Confident Congress Can Work Together To Address Health Care Issues Facing The Country

Democrats are slightly more confident in the ability of Democrats and Republicans in Congress to be able to work together on bipartisan health care legislation (41 percent) compared to independents (27 percent) and Republicans (19 percent); yet, a majority across party identification say they are either “not very confident” or “not at all confident” (58 percent, 72 percent, and 79 percent, respectively).

The Future of the Affordable Care Act and Medicaid Expansion

The 2018 midterm elections have major implications for both the future of the 2010 health care law known as the Affordable Care Act (ACA) as well as one of its most popular provisions – individual state’s expansion of the Medicaid program for low-income people.

The Affordable Care Act

With Democrats regaining a majority in the U.S. House of Representatives for the first time since 2010, and without continued efforts among Republicans to repeal the ACA, the latest KFF Tracking Poll finds a slight uptick in the public’s view of the law with 53 percent saying they view law favorably compared to four in ten who have an unfavorable view of the law. This slight shift is largely driven by Democrats with about eight in ten saying they have a favorable opinion of the law, including about half (48 percent) who have a “very favorable” view. Similarly, three-fourths of Republicans (76 percent) continue to view the law unfavorably with more than half (54 percent) saying they have a “very unfavorable” opinion of the law.

Figure 5: Post-Election Tracking Poll Finds Slight Uptick in ACA Favorability, Largely Driven By Democrats

Figure 5: Post-Election Tracking Poll Finds Slight Uptick in ACA Favorability, Largely Driven By Democrats


Similar to previous KFF Tracking Polls, many of the ACA’s provisions continue to be quite popular, even across party lines. A majority of the public – regardless of party identification – hold favorable views of all of the ACA’s provisions with one exception (fewer than half of Republicans say they have a favorable opinion of the Medicare payroll tax increases on earnings for upper-income Americans).

Table 2: Americans’ Opinions of ACA Provisions
Percent who say they have a FAVORABLE opinion of each of the following provisions of the law: Total Democrats Independents Republicans
Allows young adults to stay on their parents’ insurance plans until age 26 82% 90% 82% 66%
Creates health insurance exchanges where small businesses and people can shop for insurance and compare prices and benefits 82 91 78 71
Provides financial help to low- and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage 81 92 82 63
Gradually closes the Medicare prescription drug “doughnut hole” so people on Medicare will no longer be required to pay the full cost of their medications 81 85 82 80
Eliminates out-of-pocket costs for many preventive services 79 88 78 68
Gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults 77 91 77 55
Requires employers with 50 or more employees to pay a fine if they don’t offer health insurance 69 88 61 56
Prohibits insurance companies from denying coverage because of a person’s medical history 65 70 66 58
Increases the Medicare payroll tax on earnings for upper-income Americans 65 77 69 42
Note. Some items asked of half samples.

In previous KFF Health Tracking Polls, one of the ACA’s provisions – the individual mandate which required nearly all Americans have health insurance or pay a fine – was consistently viewed unfavorably by a majority of the public. As part of the federal tax bill passed in 2017, Congress zeroed out the dollar amount and percentage of income penalties imposed by the individual mandate. Overall, three in ten Americans (31 percent) are aware that Congress has gotten rid of the penalty for not having health insurance, while four in ten (38 percent) incorrectly say Congress has not gotten rid of this penalty and an additional three in ten (31 percent) are unsure. The results are similar among those under 65 years old who either buy their own insurance or are currently uninsured with three in ten (31 percent) aware Congress has gotten rid of the penalty for not having health insurance.

Figure 6: Most Americans Are Not Aware Congress Has Gotten Rid Of The Penalty For Not Having Health Insurance

Figure 6: Most Americans Are Not Aware Congress Has Gotten Rid Of The Penalty For Not Having Health Insurance

Medicaid Expansion

Three states (Idaho, Nebraska, and Utah) voted during the 2018 election to expand their Medicaid program to cover more low-income residents, bringing the total number of states that have expanded their Medicaid programs to 37 states including Washington, D.C. Overall, about three-fourths of the public – including 77 percent of those living in non-expansion states – have a favorable view of the ACA’s provision that gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults. In addition, a majority (59 percent) of those living in non-expansion states would like to see their state expand Medicaid to cover more low-income uninsured people while one-third (34 percent) say they want to see their state keep Medicaid as it is today. A majority of Democrats and Democratic-leaning independents say they want to see their state expand Medicaid (84 percent) while most Republicans and Republican-leaning independents want to see their state keep Medicaid as it is today (65 percent).

Figure 7: Majority Of Residents In Non-Expansion States Want Their State To Expand Their Medicaid Programs

Figure 7: Majority Of Residents In Non-Expansion States Want Their State To Expand Their Medicaid Programs

Among those living in states without Medicaid expansion who want to see their state expand their Medicaid program, nearly nine in ten (51 percent of all residents living in non-expansion states) say that if their governor and state government choose not to expand Medicaid, voters themselves should be able to decide if their state expands Medicaid.

The ACA’s 2019 Open Enrollment Period

The ACA’s sixth open enrollment period for individuals who purchase health plans on their own began on November 2, 2018 and closes in most states on December 15, 2018.1 According to the Centers for Medicare and Medicaid Services, as of November 21, 2018, 1.9 million people have signed up for insurance through the federal marketplace, which is slightly less than in previous years.2

The most recent KFF Tracking Poll finds a majority of the group most directly affected by open enrollment (those 18-64 years old who either purchase their own insurance or are currently uninsured) are unaware of the current open enrollment deadlines. About one-fourth (24 percent) of this group is aware of the current deadline to buy insurance for 2019 while six in ten (61 percent) say they “do not know” the deadline and 16 percent either offer the wrong date, incorrectly say there is no deadline or that the deadline has passed, or refuse to answer the question.

Figure 8: About One-Fourth Of Those Who Buy Their Own Insurance Or Are Uninsured Know Current Open Enrollment Deadline

Figure 8: About One-Fourth Of Those Who Buy Their Own Insurance Or Are Uninsured Know Current Open Enrollment Deadline

Slightly less than half (45 percent) of those 18-64 who either purchase their own insurance or are currently uninsured, say they have heard or seen any ads in the past thirty days from an insurance company attempting to sell health insurance. Fewer – about three in ten (31 percent) say they have heard or seen any information about how to get health insurance under the health care law.


This year’s open enrollment period has two major changes brought about by Republicans and President Trump’s administration: the removal of the penalty for not having health insurance and the introduction of short-term health insurance plans. About half of 18-64 year olds who buy their own insurance or are currently uninsured say they plan to buy their own insurance in 2019, despite the elimination of the fine for people who don’t have health insurance, while four in ten (42 percent) say they will choose to go without coverage in 2019.

Figure 9: Unclear How Changes To Individual Mandate Penalty And New Short-Term Plans May Affect Open Enrollment

Figure 9: Unclear How Changes To Individual Mandate Penalty And New Short-Term Plans May Affect Open Enrollment

One option available to those who buy their own insurance that would not have satisfied the ACA individual mandate in previous years are short-term health insurance plans. These plans cost significantly less than ACA-compliant plans but provide fewer benefits and may not pay for care for some pre-existing medical conditions.3 About one-fifth (21 percent) of those under the age of 65 who buy their own insurance or are currently uninsured say that if they had the opportunity, they would want to purchase a short-term plan. Seven in ten say they would either continue going without coverage or keep the plan they have now.

Public Support Trump Administration’s Actions on Prescription Drug Advertisements, Divided on Actions Aimed at Women’s Health and Pre-Existing Coverage

In recent months, the Trump administration has announced several actions aimed at different aspects of the U.S. health care system. The most recent KFF Tracking Poll finds the public supports the Trump administration’s proposed actions on prescription drug advertisements, even after hearing counter-arguments. The public is more divided on the administration’s actions on women’s health and protections for people with pre-existing conditions.


Earlier this year, President Trump announced a series of ideas aimed at lowering the price of prescription drugs. One of its key elements is to require drug manufacturers to publish list prices for their prescription drugs in television advertisements. About three-fourths (77 percent) favor the federal government requiring prescription drug advertisements to include a statement about how much the drug costs. In a rare instance of bipartisanship, this policy proposal is supported by a majority of Democrats (80 percent), independents (74 percent) and Republicans (77 percent).

Figure 10: Large Shares, Regardless Of Party, Favor Requiring Prescription Drug Advertisements To Include Pricing Information

Figure 10: Large Shares, Regardless Of Party, Favor Requiring Prescription Drug Advertisements To Include Pricing Information

After President Trump announced this proposal, there was some debate about how this could be implemented with opponents saying that since people often pay different prices for the same drug based on the type of insurance they have, including a price in a drug advertisement could be confusing to consumers. About one-fifth of those who originally supported this proposal change their minds after hearing this counter-argument, leaving a slight majority of the public (53 percent) continuing to support this proposal. On the other side of the debate, nearly half of those (7 percent of total) who originally opposed this proposal change their minds after hearing that putting the price of a drug in an advertisement would put pressure on drug companies to lower their prices.

Figure 11: Majority Of The Public Continue To Favor Putting Prices In Drug Advertisements Even After Hearing Counter-Arguments

Figure 11: Majority Of The Public Continue To Favor Putting Prices In Drug Advertisements Even After Hearing Counter-Arguments


On November 15, 2018, the Trump Administration issued final regulations expanding the types of employers that may be exempt from the Affordable Care Act’s (ACA) contraceptive coverage requirement to all nonprofit and closely-held for-profit employers with objections to contraceptive coverage based on religious beliefs or moral convictions, including private institutions of higher education that issue student health plans.4 Overall, six in ten (57 percent) of the public, including most women, oppose allowing employers to be exempt from the requirement to cover the full cost of prescription birth control in their plans if they object to it for religious or moral reasons.

Figure 12: Majorities Across Groups – Except For Republicans – Oppose Allowing Employers To Be Exempt From Covering Birth Control

Figure 12: Majorities Across Groups – Except For Republicans – Oppose Allowing Employers To Be Exempt From Covering Birth Control

Few individuals, on either side of the debate, change their minds about employers being exempt from covering the cost of prescription birth control for religious or moral reasons after hearing counter-arguments. About one-fourth (9 percent of total) change their minds and now oppose employer exemptions after hearing that this means some women would not be able to afford birth control. On the other side of the argument, one in eight (7 percent of total) now favor this exemption if they heard that some business owners feel like they are being forced to pay for a benefit that violates their religious or moral beliefs.

Figure 13: Few, On Either Side Of Debate, Change Minds About Employer Birth Control Coverage After Hearing Counter-Arguments

Figure 13: Few, On Either Side Of Debate, Change Minds About Employer Birth Control Coverage After Hearing Counter-Arguments


In June 2018, President Trump’s administration announced – as part of a lawsuit known as Texas v. United States, brought by 20 Republican state attorneys general – it will no longer defend the ACA’s protections for people with pre-existing medical conditions. These provisions prohibit insurance companies from denying coverage based on a person’s medical history (known as guaranteed issue), and prohibit insurance companies from charging those with pre-existing conditions more for coverage (known as community rating). The impending suit, Texas v. United States, will decide, among other things, whether both of these protections are unconstitutional and if they will be deemed invalid beginning on January 1, 2019.

The majority of the public say it is “very important” to them that the ACA’s provisions protecting those with pre-existing conditions remain law even after hearing that these protections may have led to increased insurance costs for some healthy people. Sixty-five percent of the public say it is “very important” to them that the provision that prohibits health insurance companies from denying coverage because of a person’s medical history remains law. An additional fifth (22 percent) say it is “somewhat important” this provision remains law. Similarly, about six in ten say it is “very important” that the provision that prohibits health insurance companies from charging sick people more remains law, while an additional one in five (22 percent) say it is “somewhat important.”

Figure 14: Majorities Say Pre-Existing Condition Protections Are Very Important To Them

Figure 14: Majorities Say Pre-Existing Condition Protections Are Very Important To Them

If the judge ruling on Texas v. United States decides the ACA’s protections for people with pre-existing conditions are unconstitutional, a majority of the public – including 87 percent of Democrats, 67 percent of independents, and about half of Republicans – say they would want their state to establish protections for people with pre-existing health conditions, even if this means some healthy people may pay more for coverage.

Figure 15: Majorities Say They Would Support State Action If ACA’s Pre-Existing Condition Protections Are Ruled Unconstitutional

Figure 15: Majorities Say They Would Support State Action If ACA’s Pre-Existing Condition Protections Are Ruled Unconstitutional



On Health Care, Dems Go From Running to Baby Steps

Image result for health policy

Incremental measures will dominate action on the health law in a largely gridlocked Congress.

The midterm elections all but ended the Republican push to repeal the 2010 law known as Obamacare, but as a defining issue for Democrats in their takeover of the House, health care will likely remain near the top of lawmakers’ policy and political agenda.

Newly emboldened Democrats are expected to not only push legislation through the House, but use their majority control of key committees to press Trump administration officials on the implementation of the health law, Medicaid work requirements, and insurance that does not have to comply with Obamacare rules.

Both parties are looking to address issues that voters prioritized, such as lowering prescription drug prices, though different approaches by Republicans and Democrats could mean incremental changes stand a better chance of enactment than any major bill.

Early on, lawmakers may find themselves dealing with the fallout of a court ruling that could overturn the law’s mandate that health insurance cover pre-existing conditions, putting Congress on the spot in the face of widespread voter support for those protections.

All of these issues, which dominated this year’s elections, will play out against the backdrop of the next congressional and presidential contests.

“In a lot of ways, the purpose of legislation in this Congress for the Democrats is going to be to set the agenda for the 2020 election,” said Dan Mendelson, the founder of the consulting firm Avalere.

Drug prices

Lowering drug prices is a top priority for House Democrats and President Donald Trump. Leaders of both parties identified this issue last week as a possible area for bipartisanship.

But Democrats’ more ambitious plans, like allowing Medicare to negotiate drug prices, aren’t expected to advance in the Republican Senate. Instead, issues like increasing transparency or speeding up approvals for new treatments could be ones where both parties can find agreement.

Texas Democratic Rep. Lloyd Doggett, a contender to lead the Ways and Means Health Subcommittee, is pushing a measure that would require HHS to negotiate prices for drugs covered by the Medicare Part D program. While most Democrats say they back price negotiations, there will likely be debate within the party about the details, particularly if they seem to be close to the government setting prices.

“When you start getting into anything that looks like price controls, you might get some bipartisan support for, but you also might get bipartisan support against,” said Ben Isgur, the leader of PwC’s Health Research Institute.

Democrats’ other focal points center on price-gouging for pharmaceuticals, which gained significant attention in recent years. The House Democrats’ “Better Deal” legislative agenda envisions a “price-gouging” enforcer, which would be a Senate-confirmed position to lead a new agency focused on stopping significant price increases for prescription drugs. Democrats also hope to require drug manufacturers to provide data to justify significant price increases.

Their plan would require drugmakers to justify price increases of certain amounts at least 30 days before they take effect.

Leaders in both parties have said since the election that drug pricing will be on the agenda, but have appeared skeptical of whether their efforts would yield a successful outcome.

“The jury’s out in my mind,” Democratic Rep. Pramila Jayapal said in a call with reporters last week. “If he is serious about taking on those pharmaceutical drug companies and ensuring that we can really get prescriptions filled for our seniors and negotiate prices for our pharmaceutical drugs the way we do for our VA, then we might have something we can work on.”

Mendelson predicted that even if a major bipartisan agreement to lower prices doesn’t advance in the next Congress, the Trump administration will keep taking steps that could eventually lower prices. Food and Drug Commissioner Scott Gottlieb has earned bipartisan praise for speeding new drug approvals, for instance.

The Trump administration could try to stay in command of drug pricing politics ahead of the 2020 election, he added, although Democrats will also seek to control the issue.

“There could well be significant progress over the next year or two because the administration has a lot of authority and they will use it to neutralize the issue before the 2020 election,” said Mendelson, a former Clinton administration official.

Health care law

The electrifying election-year issue of pre-existing condition protections is likely to win a House vote as Democrats seek to prove their commitment to that popular part of the law.

Both parties are bracing for a ruling from U.S. District Court Judge Reed O’Connor of Texas in a lawsuit filed by 20 state officials seeking to overturn the 2010 law. O’Connor heard oral arguments in September, although the Trump administration asked to delay a ruling until after the open enrollment period ends on Dec. 15.

If O’Connor strikes down all or part of the health care law, Democrats expect a group of state attorneys general defending the law to seek an immediate injunction and appeal the decision. Legal scholars on both sides of the aisle question the arguments of those attempting to kill the law, but the case could reach the Supreme Court.

House Democrats plan to consider a bill by Rep. Jacky Rosen of Nevada who won a Senate bid last week, that would allow the House to intervene in the case and defend the health law, aides say.

Across the Capitol, 10 Senate Republicans introduced a bill this summer to guarantee coverage of pre-existing conditions, which GOP aides say could be part of a response to the lawsuit.

Democrats have criticized the Senate GOP bill because it doesn’t require insurers to cover certain services for patients with pre-existing conditions. Republicans like North Carolina Sen. Thom Tillis, who sponsored the measure, defend it.

“If they do strike down large parts of the legislation, Sen. Tillis’ bill could be one important part of a larger health care legislative effort,” said Adam Webb, a spokesman for Tillis.

Senate Majority Leader Mitch McConnell of Kentucky declined to reveal after the election how the chamber would respond to a ruling striking down parts of the law, but called for bipartisan fixes to the health law.

A draft bipartisan stabilization bill, which has been at an impasse for nearly a year, could re-emerge in the next Congress, but it’s not clear if lawmakers can resolve a fight over abortion restrictions that blocked an agreement or how that measure could change a year later.

“The first thing we need to do is stop Republican attacks on coverage of pre-existing conditions, stop any movement toward extending these short-term plans,” Iowa Rep.-elect Cindy Axne, who defeated Rep. David Young, said in a call with reporters last week.

Top Democrats — Frank Pallone Jr.Richard E. Neal of Massachusetts, and Robert C. Scott of Virginia, who are expected to chair the Energy and Commerce, Ways and Means, and Education and Workforce committees, respectively — introduced legislation this year to shore up the health law. It would increase the size of the tax credits that help people pay their premiums and expand eligibility. It would also block Trump administration rules to expand health plans that don’t meet the 2010 law’s requirements.

Aides caution the bill could see minor changes next year based on developments since it was introduced in March and say it could be tied into a stabilization debate.

Since falling short in their efforts to overhaul the law last year, Senate Republicans pivoted to rising health care costs, a focus that will likely extend into next year. Several senators showed interest in legislation to prevent surprise medical bills, but it’s not clear what other topics could lead to bipartisan agreement, which will still be needed in the Senate even with a larger Republican majority.


Oversight of the health care law will dominate House action on the health law in a largely gridlocked Congress. House Democrats plan to bring administration officials to Capitol Hill to explain what critics call “sabotage” of the law’s insurance exchanges.

“We’ll be looking at what they’re doing administratively to undermine the operations of the Affordable Care Act and what consequences they may have caused to literally millions of people,” Minority Whip Steny H. Hoyer told reporters in September.

Oversight could touch on issues such as Trump’s funding cuts to outreach and advertising for the exchanges, reductions in enrollment help and the effects of repealing the law’s mandate to get coverage.

Maryland Rep. Elijah E. Cummings, who is expected to lead the House Oversight Committee, will likely rev up an investigation into drug companies high prices that he has been conducting as ranking member and could bring executives in to testify before the panel.

In a post-election press conference, the presumed incoming House speaker, Nancy Pelosi of California, highlighted the Energy and Commerce Committee as another “big oversight committee” that will be active.

“We do not intend to abandon or relinquish our responsibility … for accountability, for oversight and the rest,” said Pelosi. “This doesn’t mean we go looking for a fight, but it means that if we see a need to go forward, we will.”


With Divided Congress, Health Care Action Hightails It to the States

Image result for With Divided Congress, Health Care Action Hightails It to the States

Medicaid expansion was the biggest winner in last week’s elections.

Newly-elected leaders in the states will be in a stronger position than those in Washington to steer significant shifts in health care policy over the next couple of years as a divided Congress struggles with gridlock.

State Medicaid work requirements, prescription drug prices, insurance exchanges and short-term health plans are among the areas with the potential for substantial change. Some states with new Democratic leaders may also withdraw from a multistate lawsuit aimed at killing the 2010 health care law or look for ways to curb Trump administration policies.

But last week’s biggest health care winner is undeniably Medicaid expansion, with upwards of half a million low-income Americans poised to gain insurance coverage following successful expansion ballot initiatives and Democratic victories in key governors’ races.

“In state health policy, it was a big election,” said Trish Riley, executive director of the nonpartisan National Academy for State Health Policy. “It was a year when many candidates had pretty thoughtful and comprehensive proposals.”

Boost for Medicaid expansion

Voters in three deep-red states — Nebraska, Idaho and Utah — bucked their Republican lawmakers by approving ballot initiatives to extend Medicaid coverage to more than 300,000 people.

Meanwhile, Democratic gubernatorial wins in Kansas and Wisconsin boosted the chances of expansion in those states. And Maine’s new governor-elect is expected to act quickly to grow the government insurance program when she takes office in January.

The election outcomes could bring the biggest increase in enrollment since an initial burst of more than two dozen states expanded Medicaid under the 2010 health care law in the early years of the landmark law’s rollout.

“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong,” said Jonathan Schleifer, head of The Fairness Project, an advocacy group that supported the initiatives, referring to the 2010 health care law. “Americans want to live in a country where everyone can go to the doctor without going bankrupt.”

The successful ballot initiatives require state leaders to move quickly toward expansion. In Idaho, the state must submit an expansion plan to federal officials within 90 days of the new law’s approval, while Nebraska must submit its plan by April 1, according to the nonpartisan Kaiser Family Foundation. Utah’s new law also calls for the state to expand beginning April 1.

In Kansas, where Medicaid supporter Laura Kelly prevailed, state lawmakers passed expansion legislation last year only to have it vetoed by the governor. Meanwhile, Wisconsin’s new Democratic governor Tony Evers, who eked out a win over Republican incumbent Scott Walker, has said he will “take immediate action” to expand, though he faces opposition from a Republican-controlled legislature.

Expansions in the five states would bring the number of states that adopted expansion under the health law to 38, plus the District of Columbia.

Still, Democrats fell short of taking one of the biggest Medicaid expansion prizes — Florida — after Andrew Gillum’s defeat. The outcome of Georgia’s tight governor’s race was still unclear as of Monday, with Republican Brian Kemp holding a narrow lead over Democrat Stacey Abrams. Both Abrams and Gillum made health care, and Medicaid expansion in particular, central to their campaigns.

Florida might be a 2020 target for an expansion ballot initiative, along with other states such as Missouri and Oklahoma, according to The Fairness Project.

Expansion supporters also suffered defeat last week in Montana, where voters did not approve a ballot initiative that would have extended the state’s existing Medicaid expansion, which covers nearly 100,000 people but is slated to expire next year. However, state lawmakers have until June 30 to reauthorize the program, according to Kaiser.

In Maine, Democratic gubernatorial winner Janet Mills is expected to expedite expansion implementation. GOP Gov. Paul LePage stymied implementation over the past year, despite nearly 60 percent of voters approving an expansion ballot initiative in 2017.

Medicaid’s future

The midterm results carry other ramifications for Medicaid, including whether states embrace or move away from controversial work requirements backed by the Trump administration.

Gretchen Whitmer, a Democrat who won Michigan’s governor race, opposed the idea and could shift away from an existing plan to institute them that’s awaiting federal approval.

“This so-called work requirement is not for one second about getting people back to work. If it was, it would have been focused on leveling barriers to employment like opening up training for skills or giving people child care options or transportation options,” Whitmer said in a September interview with Michigan Radio. “It was about taking health care away from people.”

Kansas, Wisconsin and Maine also have work requirement proposals that new Democratic governors could reverse.

But experts also say it’s possible some states, including those with Democratic governors, could end up pursuing Medicaid work requirements if that’s what it takes to get conservative legislators to accept expansion like Virginia did earlier this year.

Nebraska Republican state senator John McCollister, who supports expansion, predicted recently that the legislature would fund the voter-approved expansion initiative. But he indicated lawmakers might pursue Medicaid work requirements too.

Marie Fishpaw, director of domestic policy studies at the conservative Heritage Foundation, warned that states expanding Medicaid would face challenges. She called expansion “a poor instrument for achieving the goal that they’re trying to achieve.”

A number of new governors, including Whitmer, could pursue the so-called “Medicaid buy-in” concept.

More than a dozen state legislatures, such as in Minnesota and Iowa, explored the idea in recent years, according to State Health and Value Strategies, part of the nonprofit Robert Wood Johnson Foundation. Nevada lawmakers passed a “Medicaid buy-in” plan last year that was vetoed by the governor.

There are a variety of ways to implement such a program, but the goal is to expand health care access by leveraging the government insurance program, such as by creating a state-sponsored public health plan option on the insurance exchanges that consumers could buy that relies on Medicaid provider networks. Illinois, New Mexico, Maine and Connecticut are among the states that could pursue buy-in programs, Riley said. States are considering the concept as a way to increase affordability and lower cost growth by getting more mileage out of the lower provider rates Medicaid pays, said Katherine Hempstead, a senior policy adviser with Robert Wood Johnson Foundation.

“So many [people] struggle with the affordability of health care,” Hempstead said. “That is an environment in which Medicaid buy-in opportunities could flourish.”

Health care law

This month’s election also carries implications for the future of states’ administration of the 2010 health care law.

States that flipped to Democratic governors could switch to creating their own insurance exchanges rather than relying on the federal marketplace, said Joel Ario, a health care consultant with Manatt Phelps & Phillips and the former head of the federal health insurance exchange office under the Obama administration. The costs of running an exchange have come down in recent years, so it’s potentially cheaper for a state to run its own, Ario said.

Trump administration actions, such as cuts in federal funding for insurance navigators that help consumers enroll and the expansion of health plans that don’t comply with the law, may make states such as Michigan or Wisconsin rethink use of the federal exchange, he said.

“If [the administration] continues to promote policies that really leave a bad taste in the mouth for Democratic governors, I think they’ll be asking questions,” Ario said.

States where governors and attorneys general offices went from red to blue are likely to pull out of a lawsuit by 20 state officials that aims to take down the health care law, he added.

Wisconsin’s Evers vowed that his first act in office will be to withdraw from the lawsuit.

“I know that the approximately 2.4 million Wisconsinites with a pre-existing condition share my deep concern that this litigation jeopardizes their access to quality and affordable health care,” Evers wrote in a letter he said he plans to send to the state attorney general.

Hempstead said that states with both Republican and Democratic leaders will likely continue to pursue reinsurance programs, which cover high-cost patients, to bolster their marketplaces.

Republican governors could also pursue waivers under a recent Trump administration guidance that allows states to circumvent some requirements of the health law under exemptions known as 1332 waivers. But experts say it’s too soon to know exactly what approaches states might take.

“It will be interesting to see what the 1332 guidance means and whether it opens doors for some things and not for others,” Hempstead said. States that shifted to Democratic governors could also look to ban some Trump-supported policies, such as expansions of short-term and association health plans that avoid the health care law’s rules.

States are also likely to take steps to address high prescription drug costs in the coming years, with a number of new governors wanting to improve transparency, explore drug importation from other countries and target price gouging, Riley said.

“There’s a long history of the states testing, fixing, tweaking and informing the national debate,” said Riley.


Trends in Health Policy and the Mid-Term Elections Results

Image result for Series: Trends in Health Policy and the Mid-Term Elections Results

Tune in to hear Avalere experts discuss potential implications of the mid-term elections on health policy. Director Chris Sloan interviews Senior Vice President Elizabeth Carpenter on the mid-term elections results and what this could mean for the future of healthcare policy.

CS: Hello, and welcome to a special mid-term elections Avalere podcast. This is the last in a three-part series we’re doing on the health policy implications of the mid-term elections, and this time, we actually have results from the mid-term elections! My name is Chris Sloan, I’m a director with the federal and state policy group here at Avalere. Today, we’re going to discuss the results of the mid-term elections and the implications for health policy going forward.

As a reminder for those of you living under rocks, the mid-term elections ended with Democrats taking control of the House while Republicans increased their lead in the Senate. In three states, Medicaid expansion ballot initiative passed, which is likely to lead to about 325,000 new enrollees in Medicaid in Idaho, Nebraska, and Utah. Also, Democratic candidates who campaigned on Medicaid expansion won the governors races in Kansas, Maine, and Wisconsin, potentially leading to another 300,000 Medicaid enrollees in those states if they follow through with expansion.

Joining me today to talk about all of this and what we can expect in healthcare from the new Democratically-controlled House is Elizabeth Carpenter. She’s the senior vice president of our federal and state policy group, and she’s the preeminent expert at Avalere in all things health policy. Thanks for being here.

EC: Thanks for having me.

CS: The exit polling for the elections showed that healthcare again was one of the top issues for voters in the elections, eight years after the passage of the ACA. Can you talk about why this issue has continued to be such a big part of campaigns and elections in U.S. politics?

EC: I think this election marked a new high in some ways in terms of how Americans thought and voted on health care. If you had asked me this question leading up to 2016, I would have focused on Americans talking about jobs and the economy, and I would have linked healthcare to jobs and the economy. People often talk about being worried about their job because they are worried about affording their health insurance and their healthcare. This year, from a domestic policy perspective, we saw healthcare at the top of the list, and when you look under the hood, what you see is that people were focused on healthcare costs and not necessarily those costs that are predictable—premiums ranked somewhat low on the list. People were very focused on surprise medical bills and certain areas where we’ve seen increased deductibles and coinsurance that are leading people to be more exposed to system costs. It’s clear that people were focused on healthcare, but they were really focused on having a surprise or unexpected healthcare expense where they were going to have to go out of pocket quite a bit at one time. As the economy has stabilized, people seem to be zeroing on the healthcare front. What I would say is, in all of our policy discussions of healthcare costs, you have to ask yourself, what is the policy doing to address that question? In many cases, I would opine that the policy is not doing much. So it is quite likely that we may see this issue continue as we head towards 2020.

CS: In that vein, a lot of the Democratic candidates this election cycle were campaigning on expansions of public programs, like Medicare for All, Medicare for More. Do we expect that to continue now that Democrats have taken control of the House? How big of an issue do you think recent campaign promises have been?

EC: I would say the Democrats face a choice in this moment about what they want their next step of health reform to look like in advance of 2020. In general, I would very much expect Democrats to use the next year or two to offer thought leadership and position their party in advance of the presidential race. What that looks like, I don’t think we know at this moment. There were a number of candidates, interestingly at the state and federal level, who embraced a Medicare for All or Medicare for More type of approach. Some of those candidates won and some didn’t, and it’s hard to pinpoint what role their position on this circular policy had in those results. But I think it is fair to say that there will be continued debate over what role Medicare and other public programs play in covering our citizens and that Democrats will need to land on something in advance of 2020.

CS: So that was one big issue in the campaign, and another big issue that was on both sides was pre-existing conditions protections that made its way into the campaign season this year. There is still a lawsuit in Texas challenging the Affordable Care Act and the pre-existing conditions now that the individual mandate is gone. Do you see this as an option for some sort of bipartisan consensus coming out of the divided congress? What do you see happening with this issue going forward?

EC: This is another issue where when you look under the hood, even people who say the same things mean potentially very different things. We had candidates on both sides of the isle running ads that talked about their desire to protect pre-existing condition protections, despite the fact that some of those candidates voted to uphold the Affordable Care Act and others voted to repeal it. You asked what might happen if we see the core go down this path where pre-existing conditions projections will be null and void and would Congress sweep in and produce a solution. On face, you could say both parties to some degree do want to maintain protections for some pre-existing conditions. In practice, how you do that gets complicated. Once you open up this particular issue, you’re going to have people on one side of the isle wanting to use it as an opportunity to do certain kinds of reforms, and you have people on the other side of the isle who want to change the insurance market in another way. We’ve heard already from Democrats, for example, who are interested in potentially pursuing limitations on some of the short-term plans, including association health plans and other types of plans that don’t meet all Affordable Care Act requirements. People have already said they want to pursue this in this congress. So you can imagine there being a real need to do something, but at the same time, you can envision how this gets complicated and partisan really quickly. The closer we get to 2020, the more complicated any kind of healthcare debate gets.

CS: Given those realities of a divided government and partisanship, are we in a holding pattern for health policy until 2020 and the next election?

EC: I think a TBD there. Based on what we’ve seen so far, I don’t think anyone holds out a lot of hope for kumbayah and bipartisan progress. At the same time, we’ve seen over the past 24-48 hours various lawmakers on both sides of the isle talking about, for example, the drug pricing issue. The important thing to remember here is that we have a president who is non-traditional in some of his thinking and not necessarily aligned with the positions of the historic Republican party, so to the degree that Congress can reach some kind of alignment, it’s quite possible the President would sign something that another president might not. But it really is up to Congress to decide if they can and want to work together. Both sides at this point are making a calculation about working together and governing is good for them heading into the next election or if fostering gridlock and highlighting differences is a better political path.

CS: Great. Well, thank you so much for being with us. That wraps up our final episode of our three-part Avalere mid-term elections podcast series. As always, watch for more updates and analysis from Avalere over the coming weeks. Feel free to reach out to us with any questions. You are listening to Avalere Podcasts.




Tired of the partisanship and dithering in Congress, voters took matters into their own hands Tuesday and largely embraced initiatives and politicians who vowed to expand Medicaid and protect coverage for pre-existing conditions.


You can’t undo an entitlement.

‘Repeal and replace’ is dead. Drug pricing reforms a likely area of bipartisan consensus.

Democrats can push Medicare For All at their own peril.

For healthcare economist Gail Wilensky, the big message that voters sent to their elected officials during Tuesday’s mid-term elections was straightforward and simple.

“Don’t mess with my healthcare,” says Wilensky, a senior fellow at Project HOPE and a former MedPAC chair.

“It’s as clear as that. There were no subtleties involved here,” she says. “That includes protections for pre-existing conditions and added coverage under Medicaid.”

Consider what happened on Tuesday:

  • Overall, Democrats wrested control of the House from Republicans in an election where healthcare was seen as the single biggest issue. Democrats ceaselessly hammered Republicans with the claim that the GOP would eliminate protections for pre-existing conditions.
  • Ballot initiatives in three bright-red Republican states all passed with healthy margins. A similar ballot initiative in Montana failed, but observers blamed the failure on an unpopular $2-per-pack tax on cigarettes that would have paid for the expansion.
  • Wisconsin Attorney General Brad Schimel, a lead plaintiff in a Texas v. Azar, was ousted by Democrat Josh Kaul, who promised to withdraw Wisconsin from the suit.
  • Three-term Wisconsin Gov. Scott Walker lost a re-election bid to Democrat Tony Evers, likely scuttling that state’s recent waiver approval for Medicaid work requirements. Evers also pledged to expand Medicaid.
  • Phil Weiser, Colorado’s Democratic Attorney General-elect, and a former Obama administration staffer, told Colorado Public Radio that one of his first actions would be to join the 17 Democratic attorneys general intervening to defend the ACA in Texas v. Azar.  

Wilensky says the mid-terms results reinforce one of the oldest truisms in politics: Once an entitlement is proffered, there’s no going back.

“There is no precedent that I’m aware of in American political history where a benefit can be taken away,” she says. “Once granted, it can be modified, it can be increased, it can be augmented in some way, but there’s no taking it away after it’s been in place.”

When Democrats took control of the House, Wilensky says, they drove a stake through the heart of the “repeal and replace” movement.

“Republicans couldn’t even get that done when they control both houses of Congress, she says. “It’s a non-issue, in part because a lot of Republicans support major provisions of the Affordable Care Act.”

With repealing the ACA off the table, Democrats and Republicans might find common ground on issues such as drug pricing.

“That’s clearly is the most obvious, in general, but the specifics of what you want to do become much more challenging,” Wilensky says. “Typically, Democrats want to use administered pricing the way that we use administer pricing in parts of Medicare. I don’t know how much Republican support there is for that.”

The two parties could reach some sort of bipartisan agreement on Medicare Part B drugs, Wilensky says, because it’s a smaller program and the drugs are generally much more expensive.

“Most members of Congress are not talking about messing around with Part D, the ambulatory prescription drug coverage,” Wilensky says. “So it really has to do either with the expensive infusion drugs that are administered in the physician’s office or maybe something about drug advertising. Even then, it’s going to be hard lift when you actually get down to the specifics.”

Besides, Wilensky says, it’s not the cost of drugs that’s at the heart of voter agitation.

“You have to unpack what they’re saying to figure out what they’re actually pushing for,” she says. “People couldn’t care less about drug prices. They only care about what it costs them. So when they talk about drug prices they mean, ‘I want to spend less for the drugs I want, and I don’t want any constraints about what I can order.’

More likely, she says, common ground could be found in arcane areas such as mandating greater transparency for pharmacy benefits managers, and changing PBMs’ rebate structure.

Wilensky warns that giddy Democrats should learn from the mistakes of Republicans in the mid-terms and not attempt to force a Medicare-For-All solution on a wary public.

“First of all, they’re going to have to define what it means,” she says. “But, you have to be very careful because historically there’s not been warm and fuzzy response to taking away people’s employer-sponsored insurance.”

“Again, historically, when candidates mess around with employer-sponsored insurance they have gotten themselves into trouble,” she says. “Most people would like to keep what they have, because keeping what you have is much safer than going with something as yet to be defined.”



Healthcare Triage News: Election Results Impact the ACA, Medicaid Expansion, and Marijuana

Image result for Healthcare Triage News: Election Results Impact the ACA, Medicaid Expansion, and Marijuana

Yesterday’s election results have a lot of impact on health care in the United States. The new Democratic House of Representatives and the ACA, expansion of Medicaid in red states, and medical and recreational marijuana are all affected by last nights returns.



What the 2018 Midterm Elections Means for Health Care

Whatever you want to call the 2018 midterm elections – blue wave, rainbow wave, or purple puddle – one thing is clear: Democrats will control the House.

That fundamental shift in the balance of power in Washington will have substantial implications for health care policymaking over the next two years. Based on a variety of signals they have been sending heading into Tuesday, we can make some safe assumptions about where congressional Democrats will focus in the 116th Congress. As importantly, there were a slew of health care-related decisions made at the state level, perhaps most notably four referenda on Medicaid expansion.

In this post, I’ll take a look at which health care issues will come to the fore of the Federal agenda due to the outcome Tuesday, as well as state expansion decisions. And it should of course be noted that, in addition to positive changes Democrats are likely to pursue over the next two years, House control will allow them to block legislation they oppose, notably further GOP efforts to repeal the Affordable Care Act (ACA).

Drug Pricing

Democrats have long signaled they consider pharmaceutical pricing to be one of their highest priorities, even after then-candidate Trump adopted the issue as part of his campaign platform and maintained his focus there through his tenure as President.

While aiming to use the issue to drive a wedge between President Trump and congressional Republicans, who have historically opposed government action to set or influence prices, Democrats will also strive to distinguish themselves by going further on issues like direct government negotiation of Medicare Part D drug reimbursement.

Relevant House committee chairs, perhaps especially likely Oversight and Investigations chair Elijah Cummings (D-MD), will also take a more aggressive tack in investigating manufacturers and other sector stakeholders for pricing increases and other practices. Democratic leaders believe it will be easier to achieve consensus on this issue than on more contentious issues like single payer (more detail below) among their diverse caucus, which will include dozens more members from “purple” districts as well as members on the left flank of the party

Preexisting Condition Protections

If you live in a contested state or district, you have probably seen political ads relating to protecting patients with preexisting conditions. As long as a Republican-supported lawsuit seeking to repeal the ACA continues, Democrats believe they can leverage this issue to demonstrate the importance of the ACA and their broader health care platform.

A three-legged stool serves under current law to protect patients with chronic conditions: (1) the ban on preexisting condition exclusions; (2) guaranteed issue; and (3) community rating. Democrats will likely seek to bolster these protections with measures to shore up the ACA exchange markets. In the same vein, they will likely strive to rescind Trump Administration proposals to expand association-based and short-term health plans, which put patients with higher medical costs at risk by disaggregating the market.


Congressional Democrats believe that there were some stones left unturned in this year’s opioid-related legislation, especially regarding funding for many of the programs it authorized. This is a priority for likely Ways & Means Committee Chair Richie Neal (D-MA) and could potentially be a source of bipartisan compromise.

Medicare for All

While this issue could become a bugaboo for old guard party leaders, the Democratic base will likely escalate its calls for action on Medicare for All now that the party has taken the House. Because the details of what various camps intend by this term are still vague (some believe it is tantamount to single payer, others view it as a gap-fill for existing uninsured, etc.), we will likely see a variety of competing proposals arise in the coming two years. Expect less bona fide committee action and more of a public debate aired via the presidential primary season that will kick off about, oh, right now.

Surprise Bills

The drug industry is not the only health care sector that can expect heightened scrutiny of their pricing practices now that Democrats control the people’s chamber. Most notably, the phenomenon of surprise bills (unexpected charges often stemming from a hospital visit) has risen as a salient issue for the public and thus a political winner for the party. Republicans have shown interest in this issue as well, so it could be another source of bipartisanship next year.

Regulatory Oversight

Democrats believe they are scoring well with the public, and certainly their base, every time they take on President Trump. The wide range of aggressive regulation (and deregulation) the Administration has pursued will be thoroughly investigated and challenged by Democratic committee leaders, especially administration efforts to dismantle the ACA and to test the legal bounds of the hospital site neutrality policy enacted in the Bipartisan Budget Act (BBA) of 2015.


While it instituted permanent policies for Medicare physician payments and some other oft-renewed ‘extenders’, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 left a variety of policies in the perennial legislative limbo of needing to be repeatedly extended. While the policies in the Medicare space have dwindled to subterranean, though not necessarily cheap, affairs like the floor on geographic adjustments to physician payments, a slew of Medicaid-related and other policies are up for renewal in 2019.

For example, Medicaid Disproportionate Share Hospital (DSH) payments face a (previously delayed) cliff next year. That and the most expensive extender, ACA-initiated funding for community health centers, alone spring the cost of this package into the high single digit billions at least, driving a need for offsetting payment cuts and creating a vehicle for additional policy priorities.

A likely addition to this discussion will be the fact that Medicare physician payments, per MACRA, are scheduled to flatline for 2020-2025 before beginning to increase again, albeit in divergent ways for doctors participating in the Merit-Based Incentive Payment Program (MIPs – 0.25 percent/year) and Advanced Alternative Payment Models (APMs – 0.75 percent/year). The AMA assuredly noticed this little wrinkle in the celebrated legislation but hundreds of thousands of doctors probably did not.

Medicaid Expansion

Of the variety of state-level health policy decisions voters made on Tuesday, perhaps the most significant related to Medicaid expansion. In there states where Republican leaders have blocked expansion under the ACA – Nebraska, Idaho, and Utah – voters endorsed it via public referenda. Increasing the Medicaid eligibility level in those three states to the ACA standard will bring coverage to approximately 300,000 people.

Notably, voters in Montana rejected a proposal to continue funding the Medicaid expansion the state enacted temporarily in 2015 by an increase to the state’s tobacco tax. Their expansion is now scheduled to lapse in July 2019 if the legislature doesn’t act to maintain it. If they do not act, about 129,000 Montanans will lose Medicaid coverage.

Finally, Democratic gubernatorial wins in Maine, Kansas, and Wisconsin will make Medicaid expansion more likely in those states.

As they say, elections have consequences. While the Republican-controlled Senate and White House can block any Democratic priorities they oppose, the 2018 midterm elections assure a busy two years for health care stakeholders.




The most significant developments of the night focused around Medicaid expansion, how healthcare leaders who ran for public office fared in the elections, and several down-ballot healthcare initiatives.


Healthcare leaders who were elected: Gov. Rick Scott, Lauren Underwood, RN, and former HHS Secretary Donna Shalala.

Races where healthcare was a major factor: mixed bag for vulnerable House Republicans who voted to repeal-and-replace the ACA, as well as Medicare for All proponents.

Healthcare ballot initiatives: Three states approve Medicaid expansion, one does not; Massachusetts votes down Question 1.

The 2018 midterm elections are over but made a significant impact on healthcare policies at the federal and state level across the country, while also determining who will be in office to enact them.

The future of healthcare policymaking will be influenced by the decisions made by millions of voters on Tuesday night, as Democrats took back the House while Republicans held onto control in the Senate.

Healthcare was a top priority for voters as they made their way to the polls to vote on issues such as Medicaid expansion and the healthcare leaders seeking to represent them on Capitol Hill.

Below are some of the most significant healthcare-related developments from the 2018 midterms:


Three traditionally conservative states joined Maine in approving Medicaid expansion via ballot initiative, while voters in Montana sank the measure which was attached to a proposed tobacco tax hike proposal.

More than 300,000 residents across Nebraska, Idaho, and Utah are likely to receive extended Medicaid coverage as a result of expansion. The number of places with Medicaid expansion now totals 37 states as well as the District of Columbia.

Support for the measure exceeded 60% in Idaho, while Utah and Nebraska approved Medicaid expansion with 54% and 53% of the vote, respectively.

Montana, voting on the most expensive ballot measure in state history, voted down the expansion proposal, which will sunset at the end of the year.


Last night, Massachusetts voters had their say on ballot Question 1, which sought to implement nurse- to-patient ratios in hospitals and other healthcare settings.

It was met with a resounding ‘no’ from the electorate, with about 70% voting against the measure and almost 30% voting for it.

For months, the law has been hotly debated. Those in favor said it would improve patient safety and care. Those opposed said it didn’t account for patient acuity and would create a financial burden on hospitals and healthcare systems.

Had the law passed, Massachusetts would have joined California as the only other state to require that level of mandatory ratios.


As expected, two of the three governors who received federal approval for Medicaid work requirements and were on the ballot for the midterms, Gov. Chris Sununu, R-N.H. and Gov. Asa Hutchinson, R-Ark., cruised to election night victories.

Sununu defeated Democratic challenger Molly Kelly by a 52% to 46% margin while Hutchinson dispatched Democratic opponent Jared Henderson with 65% of the vote.

The most vulnerable of the three Republican incumbents, Wisconsin Gov. Scott Walker, was unseated by Democratic opponent Tony Evers by just over a single percentage point.

Wisconsin had just received CMS approval for its Medicaid work requirements last week, which was the latest development in a race dominated by healthcare issues that ultimately pushed Walker out of office. 


Oklahoma voters rejected the Walmart-backed Question 793, which would have amended the Oklahoma Constitution to give optometrists and opticians the right to practice in retail stores. Walmart gave nearly $1 million in the third quarter alone to proponents of the initiative, which was narrowly defeated by less than 6,000 votes.

Nevada voters approve exemption of durable medical goods from state sales tax. Local media in Nevada are reporting that more than 67% of voters in state voted for Question 4, which amends the Nevada Constitution to require the state legislature to exempt some durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax.

California voters roundly rejected an initiative to cap the profits of kidney dialysis providers at 15% above direct patient cost. However, Golden State voters approved a ballot initiative that authorizes $1.5 billion in bonds to fund capital improvements at the state’s 13 children’s hospitals.


The race in Kentucky’s 6th Congressional District set the tone for the night among House races, as Rep. Andy Barr, who was targeted by Democrats for his support of House GOP plans to repeal-and-replace the ACA, faced Democratic challenger Amy McGrath, who voiced support in Medicare-for-All legislation.

A neck-and-neck race throughout the early part of the evening, Barr ultimately defeated McGrath, but other vulnerable House Republicans did not fare as well.

In New York, Rep. John Faso lost to Democratic challenger Antonio Delgado in the 19th Congressional District, a race highlighted by disagreements over healthcare policy, and Rep. Claudia Tenney, a vocal critic of the ACA, was unseated by Democratic opponent Anthony Brindisi in the 22nd Congressional District.

Sen. Bernie Sanders, I-VT, and Rep. Pramila Jayapal, D-Wash., two of the most notable proponents of Medicare for All were reelected, while newcomer Alexandria Ocasio-Cortz, a self-described Democratic Socialist, became the youngest woman ever elected to Congress in New York’s 14th Congressional District.

However, other Medicare for All proponents did not perform as expected across the country, with Tallahassee Mayor Andrew Gillum losing a tight gubernatorial race in Florida to Republican Rep. Ron DeSantis, and Rep. Beto O’Rourke falling to Republican incumbent Sen. Ted Cruz in the Texas Senate race.


After a lengthy primary season and contentious general election cycle, numerous healthcare leaders won their respective elections Tuesday night.

Healthcare was one of the most prominent issues concerning voters in the midterm election cycle, punctuated by more than 60 declared candidates with healthcare backgrounds running for public office in 2018.

Around 35 candidates made it to the general election ballot and more than two dozen received a stamp of approval from the voters.

Most notably were Gov. Rick Scott, former head of Columbia/HCA, who won a neck-and-neck race against Sen. Bill Nelson, D-Fla.,Lauren Underwood, RN, a former HHS adviser under former President Barack Obama, who defeated Rep. Randy Hultgren, R-Illi., and former HHS Secretary Donna Shalala, who won a hotly contested campaign in Miami.



Health Care Is on Agenda for New Congress

After months of polls, mailbox fliers, debates and seemingly endless commercials, the mid-term elections are over and the results are in. As predicted by many, the Democrats have won back the majority in the U.S. House of Representatives, while the Republicans have expanded their majority in the Senate.

This means that for the first time since 2015 we have a divided Congress, which leaves me pondering the possible consequences for Scripps Health and the broader health care sector.

Without a doubt, health care will be on the agenda for both parties over the coming months. That became apparent during pre-election campaigning as voters on both sides of the political spectrum voiced concerns about a wide range of health care-related issues.

Exit polls found that about 41 percent of voters listed health care as the top issue facing the country, easily outpacing other issues such as immigration and the economy.

That’s really no surprise. Health care affects all of us, whether we’re young or old, poor or well off, or identify as more conservative or more liberal. And despite all of the division around the country, most Americans seem to agree on at least a few things – health care costs too much, more needs to be done to rein in those costs, everyone should have access to health insurance, and pre-existing condition shouldn’t be a disqualifier for getting coverage.

When the new Congress convenes on Jan. 3, a wide range of health care issues will be on the agenda.

Here are a few of the issues that I’ll be watching as our lawmakers adjust to the reshuffled political dynamics in Washington.

  • Repealing elements of the Affordable Care Act (ACA) is likely off the table now that Democrats control the House. Previously, House Republicans had voted to change a number of ACA provisions that required health insurance policies to cover prescription drugs, mental health care and other “essential” health benefits. But even before the election, Republicans had reassessed making changes to measures that protect people with pre-existing conditions as that issue gained traction with voters.
  • Efforts to expand insurance coverage and achieve universal health care will likely increase. A number of newly elected Democrats vowed to push for a vote on the single-payer option, but other less politically polarizing options such as lowering the eligibility age for Medicare and expanding Medicaid likely will draw more support.
  • While Republicans used their majority in the House to reduce the burden of government regulations in health care and other industries, Democrats might use their new-found power to initiate investigations on a wide range of matters such as prescription drug costs.

We could see some significant changes take place at a more local level as well. On Tuesday, voters in three states approved the expansion of Medicaid, the government program that provides health care coverage for the poor.

And here in California, we will be watching newly elected Governor Gavin Newsom to see what plans he will put forward for expanding health care coverage in this state.

At Scripps, we believe everyone should have access to the health care services that they need, and we have worked hard in recent years to do all that we can to bring down the costs of delivering that care to our patients.

In this new world of divided government, gridlock likely will prevail and President Trump’s initiatives will struggle in the Democrat-controlled House. Everyone will be focused on positioning themselves and their party for the next presidential and congressional elections in two years.

Compromise and bipartisanship are clearly the best options for addressing the health care challenges we now face in ways that have the best chance to win wide public support.

If Democrats in the House fail to reach across the aisle to Republicans or try to make too many changes too quickly, they surely will face many of the same pitfalls that confronted Republicans over the last two years.




On Tuesday, Massachusetts voters will face a ballot question on mandating nurse-to-patient ratios.

Nurse staffing ratios are one of the most hotly debated issues within the nursing profession. Those in favor say the limits improve patient safety and care. Those against them say ratios don’t account for patient acuity and would create a financial burden on hospitals and healthcare systems.

Now the public gets to weigh in on the issue. On Nov. 6, Massachusetts voters will face ballot Question 1, which would implement nurse to patient ratios in hospitals and other healthcare settings. The ratios vary according to the type of unit and level of care provided.

The Massachusetts Nurses Association supports the law, while hospitals, health systems and some other nursing professional organizations oppose it.

Both sides have pumped millions of dollars into the debate.

Voters seem to be split on the issue as well.

According to an October 25 to 28  WBUR poll,  58% of voters say they are against Question 1. This is a change from September when respondents to a previous WBUR poll were more evenly split with 44% in favor, 44% against, and 12% undecided.

Massachusetts is not completely unfamiliar with nurse-patient staffing ratios. In 2014, Massachusetts passed a law requiring 1-to-1 or 2-to-1 patient-to-nurse staffing ratios in intensive care units, as guided by a tool that accounts for patient acuity and anticipated care intensity.

However, an analysis by physician-researchers at Beth Israel Deaconess Medical Center found those regulations were not associated with improvements in patient outcomes.

Should the law pass, Massachusetts will join California as the only other state to require this level of mandatory ratios. In California, the law supporting ratios was passed in 1999 and was then rolled out in a staggered fashion until it was in full-effect in 2004.

Will mandatory ratios become a reality for those in the Baystate? That will be known, most-likely, in just a few short days.