20% of Americans are deferring healthcare because of cost, poll finds

https://www.beckershospitalreview.com/finance/20-of-americans-are-deferring-healthcare-because-of-cost-poll-finds.html?origin=rcme&utm_source=rcme

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Americans are delaying medical care as they struggle with its affordability, according to the latest NPR-IBM Watson Health poll.   

The survey of more than 3,000 U.S. households in July found about 20 percent of respondents or someone in their household had postponed or canceled a healthcare service due to cost in the prior three months. 

Younger respondents were more likely to put off their healthcare needs. Thirty-four percent of respondents under 35 said they deterred care because of cost, compared with 8 percent of respondents 65 and older.

The poll also found 26 percent of respondents or someone in their household had difficulty paying for some type of healthcare service in the prior three months.

Again, younger respondents were more likely to experience trouble. Forty-one percent of respondents under 35 said they or a member of their household struggled to pay for a healthcare service, compared to 11 percent of respondents 65 and older and 26 percent of respondents ages 35 to 64.

The poll found 66 percent of respondents said they received a prescription in the prior three months, and 97 percent of those respondents had it filled. Of the respondents who said they had a prescription filled, 19 percent reported they had trouble paying for it.

Access the full poll results here.

 

Middle-income Americans paying more for health insurance

https://www.healthcaredive.com/news/middle-income-americans-paying-more-for-health-insurance/543903/

Dive Brief:

  • Middle-income families are spending more of their incomes on health insurance as average premiums skyrocketed in 2017 after modest rate increases earlier this decade, The Commonwealth Fund found in a new report.
  • Average employee contributions rose to nearly 7% of median income for single and family plans compared to 5.1% a decade ago. Premium contributions were 8% of median income or more in 11 states, including Louisiana, which had the highest percentage (10.2%).
  • The contributions and potential out-of-pocket spending for single and family policies was $7,240 in 2017. That was 11.7% of median income and an increase from 7.8% a decade ago.

Dive Insight:

Cost and price variations between areas aren’t anything new. A recent Network for Regional Healthcare Improvement found healthcare usage and pricing drive variation between states’ total healthcare costs. The report also found vast differences in costs between five states studied.

Overall, national health spending has slowed in recent years. The CMS Office of the Actuary reported this month that national health spending grew 3.9% ($10,739 per person) in 2017. It was the second consecutive year of slower healthcare spending growth. The slower cost growth is connected to fewer people receiving care.

The Commonwealth Fund found large differences between states. For instance, the average annual premium contributions for single-person plans ranged from $675 in Hawaii to $1,747 in Massachusetts. Michigan saw the cheapest premiums in family plans at $3,646 while Delaware had the highest at $6,533.

The average annual deductible for single-person policies increased to more than $1,800 in 2017. The gap was between $863 (Hawaii) and about $2,300 (Maine and New Hampshire). Three states (Florida, Mississippi and Tennessee) had average deductibles more than 6% of median income.

Premiums for employer health plans, which is how most Americans get coverage, increased 4.4% for single plans and 5.5% for family plans in 2017. All but five states saw higher single-person premiums with eight states averaging more than $7,000 (Alaska, Connecticut, Delaware, Massachusetts, New Jersey, New York, Rhode Island and Wyoming).

Meanwhile, family premiums increased in 44 states and were $20,000 or more in seven states (Alaska, Connecticut, Massachusetts, New Jersey, New York, West Virginia and Wyoming) and the District of Columbia.

The cost of health insurance is increasing faster than wage growth — and the Commonwealth Fund found that the added cost isn’t leading to higher-quality health insurance. The issue is especially a problem in southern states with lower median incomes, such as Mississippi.

The group suggested policymakers could tackle the problem of rising healthcare costs in a couple of ways.

Congress could provide more tax credits to people with employer-sponsored insurance, require businesses to improve plan benefit design to cover more services before employees reach their deductibles and offer refundable tax credits to offset out-of-pocket costs.

Other potential efforts include connecting provider payments to value and outcomes, addressing the concentration of payer and provider markets and slowing prescription drug cost growth. “Policymakers will need to recognize that the increasing economic strain of healthcare costs facing middle-income and poor Americans is driven by multiple interrelated factors and will require a comprehensive solution,” according to the report.

 

Federal Subsidies Could Expand to Health Programs That Violate Obamacare

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 The Trump administration said Thursday that states could bypass major requirements of the Affordable Care Act by using federal funds for a wide range of health insurance programs that do not comply with the law.

Federal officials encouraged states to seek waivers from provisions of the law that specify who is eligible for premium subsidies, how much they get and what medical benefits they receive.

It was “a mistake to federalize so much of health care policy under the Affordable Care Act,” Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, told state officials at a conference in Washington.

The new policy outlined by the administration on Thursday upends a premise of the Affordable Care Act: that federal subsidies can be used only for insurance that meets federal standards and is purchased through public marketplaces, also known as insurance exchanges.

Under the new policy, states could use federal subsidies to help people pay for employer-sponsored insurance. Consumers could combine federal funds with employer contributions to buy other types of insurance.

Under the Affordable Care Act, premium tax credits are available to people with incomes up to four times the poverty level, roughly $83,000 a year for a family of three. With a waiver, states could provide assistance to higher-income families.

The Trump administration laid out templates for state programs — waiver concepts — that could significantly depart from the model enacted by Congress in 2010.

Alex M. Azar II, the secretary of health and human services, said states could use the suggestions to “create more choices and greater flexibility in their health insurance markets, helping to bring down costs and expand access to care.”

Democrats assailed the initiative as an audacious effort to undermine the Affordable Care Act. And they said the administration was ignoring the midterm election success of Democrats who had promised to defend health care that they said was threatened by President Trump and Republicans in Congress.

“The American people just delivered an overwhelming verdict against Republicans’ cruel assault on families’ health care,” said the House Democratic leader, Nancy Pelosi of California. “But instead of heeding the will of the people or the requirements of the law, the Trump administration is still cynically working to make health insurance more expensive and to leave more Americans without dependable coverage.”

Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, said the administration was creating a fast lane for swift approval of “junk insurance.”

The Affordable Care Act prohibits insurers from denying coverage or charging higher premiums to people with pre-existing medical conditions. At campaign rallies this fall, Mr. Trump repeatedly promised: “We will always protect Americans with pre-existing conditions. Always.”

Ms. Verma said Thursday that “the A.C.A.’s pre-existing condition protections cannot be waived.

But states could use federal funds to subsidize short-term plans and “association health plans,” in which employers band together to provide coverage for employees. Such plans are free to limit or omit coverage of benefits required by the Affordable Care Act, such as mental health care, emergency services and prescription drugs.

A provision of the Affordable Care Act allows waivers for innovations in state health policy. The federal law stipulates that state programs must provide coverage that is “at least as comprehensive” as that available under the Affordable Care Act and must cover “at least a comparable number” of people.

Two powerful House Democrats said the new guidance issued by the Trump administration was illegal because it did not meet the standards for waivers set forth in the Affordable Care Act.

“It is contrary to the plain language of the statute, and it appears to be part of the administration’s ideologically motivated efforts to sabotage the Affordable Care Act,” said a letter sent to Mr. Azar by Representatives Frank Pallone Jr. of New Jersey and Richard E. Neal of Massachusetts.

In issuing the guidance, they said, Mr. Azar also violated the Administrative Procedure Act, which generally requires agencies to provide an opportunity for public comment before adopting new rules.

Republican governors have been pleading with federal officials to give states more authority to regulate health insurance.

Paul Edwards, a deputy chief of staff to Gov. Gary Herbert of Utah, a Republican, said, “Utah welcomes all efforts that give us maximum flexibility to structure our health care programs to the unique needs of our citizens.” State officials “will look closely at how these new rules could benefit Utahns,” he said.

Brenna Smith, a spokeswoman for Gov. Kim Reynolds of Iowa, a Republican, said the governor “has a proven track record of expanding health care options for Iowans and is eager to see the new opportunities this proposal might open up.”

Iowa tried last year to get a waiver under Obama-era guidance, seeking essentially to opt out of the Affordable Care Act marketplace by offering customers a single plan with lower premiums and a high deductible.

Ms. Reynolds ultimately withdrew the request in frustration, saying at the time that “Obamacare’s waiver rules are as inflexible as the law itself.”

One option for states is to take federal funds and put the money into accounts that consumers could use to pay insurance premiums or medical expenses.

Likewise, Ms. Verma said: “States can develop a new state premium subsidy structure and decide how premium subsidies should be targeted. States can set the rules for what type of health plan is eligible for state premium subsidies.”

She was speaking Thursday at a conference of the American Legislative Exchange Council, a conservative group that promotes limited government and drafts model legislation.

 

New insurance guidelines would undermine rules of the Affordable Care Act

https://www.washingtonpost.com/national/health-science/new-insurance-guidelines-would-undermine-rules-of-the-affordable-care-act/2018/11/29/ff467f46-f357-11e8-aeea-b85fd44449f5_story.html?utm_term=.c279fcb895a6&wpisrc=al_news__alert-hse–alert-national&wpmk=1

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The Trump administration is urging states to tear down pillars of the Affordable Care Act, demolishing a basic rule that federal insurance subsidies can be used only for people buying health plans in marketplaces created under the law.

According to advice issued Thursday by federal health officials, states would be free to redefine the use of those subsidies, which began in 2014. They represent the first help the government ever has offered middle-class consumers to afford monthly premiums for private insurance.

States could allow the subsidies to be used for health plans the administration has been promoting outside the ACA marketplaces that are less expensive because they provide skimpier benefits and fewer consumer protections. In an even more dramatic change, states could let residents with employer-based coverage set up accounts in which they mingle the federal subsidies with health-care funds from their job or personal tax-deferred savings funds to use for premiums or other medical expenses.

If some states take up the administration’s offer, it would undermine the ACA’s central changes to the nation’s insurance system, including the establishment of nationwide standards for many kinds of health coverage sold in the United States.

Another goal of the ACA, the sprawling 2010 law that was President Barack Obama’s preeminent domestic accomplishment, was to concentrate help on the individual insurance market serving people who do not have access to affordable health benefits through a job. Prices were often out of control and discrimination against unhealthy people was more prevalent before the ACA imposed required benefits, prohibited insurers from charging more to people with preexisting conditions and created a federal health exchange and similar state-run marketplace in which private insurance companies compete for customers.

The ACA health plans have been the only ones for which consumers can use the subsidies, designed to help customers with incomes up to the middle class — 400 percent of the federal poverty line — afford the premiums.

The new advice, called “waiver concepts” because they are ideas for how states could get federal permission to deviate from the law’s basic rules, stray from both of those goals. And it would allow states to set different income limits for the subsidies — higher or lower than the federal one.

The day before they were released by Seema Verma, administrator of the Department of Health and Human Services’ Centers for Medicare and Medicaid Services, an analysis by the Brookings Institution questioned the legality of the content and method of these concepts. The analysis by Christen Linke Young, a Brookings fellow and HHS employee during the Obama administration, contends that “there are serious questions” about whether the changes are allowable under the law and that “at the very least, it is likely invalid” for CMS to issue the advice to states without going through the formal steps to change federal regulations.

In a statement Thursday, HHS Secretary Alex Azar said: “The Trump administration is committed to empowering states to think creatively about how to secure quality, affordable healthcare choices for their citizens.” He said the four recommendations issued Thursday, including new accounts in which consumers could pool federal subsidies and other funds, are intended to “show how state governments can work with HHS to create more choices and greater flexibility in their health insurance markets, helping to bring down costs and expand access to care.”

In a midday speech before a gathering of the conservative American Legislative Exchange Council, Verma delivered a broadside against the health-care law in explaining the rationale for freeing states to rework health policies on their own. “It was such a mistake to federalize so much of health care in the ACA,” said Verma, who worked as a consultant to states before becoming one of Trump’s senior health-care advisers. While the law sought to make health coverage more available and affordable, she said, “the insurance problem has not been solved. For many Americans it’s even been made worse.”

In urging states to consider the changes, CMS is renaming a provision of the law, known as 1332, which until now has mainly been used to give states permission to create programs to ease the burden on insurers of high-cost customers. CMS is switching the name to “State Relief and Empowerment Waivers,” emphasizing the administration’s desire to hand off health-care policies to states.

The changes go beyond a variety of other steps Trump administration health officials have taken in the past year to weaken the ACA, which the president has opposed vociferously.

Until now, they have focused on bending the ACA’s rules for health plans themselves. The administration has rewritten regulations to make it easier for Americans to buy two types of insurance that is relatively inexpensive because it does not contain all the benefits and consumer protections that the ACA typically requires.

The new steps go further by undercutting the basic ACA structure of the individual insurance marketplaces created for those who cannot get affordable health benefits through a job.

During a conference call with journalists, Verma said that no state would be allowed to retreat from a popular aspect of the ACA that protects people with preexisting medical conditions from higher prices or an inability to buy coverage.

She said that, in evaluating states’ proposals, CMS would focus on several considerations, including whether changes would foster comprehensive coverage and affordability and would not increase the federal deficit. She said federal officials would favor proposals that help, in particular, low-income residents and people with complex medical problems.

Verma reiterated an administration talking point that insurance rates have escalated since the ACA was passed and that health plan choices within ACA marketplaces have dwindled. However, the current ACA enrollment period, lasting until mid-December, is different from the previous few because prices for the most popular tier of coverage have stabilized in many places and more insurers are taking part in the marketplaces.

 

ACA Slow Enrollment as Uninsured Rate Remains Steady

https://www.healthaffairs.org/do/10.1377/hblog20181120.831184/full/

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In most states across the country, the open enrollment period for 2019 began on November 1 and will end on December 15, 2018. As we near the halfway point for enrollment—at least for the states with a federal marketplace—recent federal data suggests that enrollment in Affordable Care Act (ACA) marketplace plans is lagging relative to last year.

In its “week 2” enrollment snapshot, the Centers for Medicare and Medicaid Services (CMS) announced that nearly 1.2 million consumers selected a plan between November 1 and November 10 in the 39 states that use HealthCare.gov. Of these consumers, about 275,000 were new consumers while about 901,000 were renewing their coverage from last year. This reflects a significant increase from the first three days of open enrollment when about 371,000 consumers selected a plan.

“Week 2” plan selections are down by about 302,000 consumers relative to last year. This can be read as between an 8 to 13 percent decline in plan selections compared to last year, when a total of 11.8 million consumers in all 50 states and DC selected or were automatically reenrolled in a marketplace plan. Enrollment remained largely stable from 2017 to 2018 despite a shortened open enrollment period and significant cuts to advertising and navigator funding.

This year, however, brings additional changes that could be contributing to what is, at least so far, depressed enrollment through HealthCare.gov. These changes include repeal of the individual mandate penalty; 2019 is the first year that consumers will no longer pay a penalty for being uninsured under the ACA. In addition, new federal rules are enabling expanded access to non-ACA plans (such as short-term, limited-duration insurance and association health plans). These non-ACA plans typically have a much lower premium than ACA plans and could lure consumers away from the marketplace.

It is too early to tell if the reduced enrollment trend will hold and if this pattern will continue. Enrollment may increase significantly before the December 15 deadline, and millions of Americans will enroll in coverage before the end of the year.

The declines are, however, significant. The former chief marketing officer for HealthCare.gov recently noted that the data “should be a wake-up call to everyone who cares about people having health care … on the need to step up efforts to raise awareness.” CMS intends to release enrollment snapshots on a weekly basis. Each snapshot also includes point-in-time estimates of call center activity and visits to HealthCare.gov and CuidadoDeSalud.gov, among other data.

The new open enrollment data comes at a time when the uninsured rate continues to remain steady. Data from the National Center for Health Statistics—in reports both from late August and November—shows that the uninsured rate of about 8.8 percent for 2018 remains largely unchanged from 2017. Although there was not a significant shift from 2017 to 2018, there has been a sizable drop in the uninsured rate since the ACA was enacted in 2010. Between 2010 and the first six months of 2018, the uninsured rate dropped from 16 percent (48.6 million people) to 8.8 percent (28.5 million people).

 

 

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

https://www.rollcall.com/news/policy/divided-congress-health-care-action-states

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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

http://avalere.com/expertise/life-sciences/insights/series-trends-in-health-policy-and-the-mid-term-election-results

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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.