Healthcare policy after the 2026 midterms

Although the Nov. 3 election results gave Democrats control of Congress for the next two years, the prospects for sweeping changes to healthcare policy are murky.

The Senate could hinder legislative activity because Republicans will have the numbers to block bills from proceeding to formal votes. Bills generally require a 60-vote majority to avoid filibusters, although the budget reconciliation process allows legislation to pass with a simple majority and generally is available once or twice per fiscal year.

Even if Democrats go that route, the party could have a hard time enacting major changes to the healthcare provisions in H.R. 1, the One Big Beautiful Bill Act (OBBBA), with President Donald Trump wielding veto power.

“[Trump] will view a policy that amends the One Big Beautiful Bill Act in favor of hospitals as a concession to Democrats,” John Barkett, managing director in BRG’s Healthcare Transactions and Strategy Practice, said during a pre-election media briefing. “And therefore, he’ll be looking for something in return.”

Such negotiations may ramp up when it comes time to pass a government funding bill, although with funding set to expire Dec. 11, the next instance will take place before the next Congress is seated. Another such circumstance could arise if the U.S. Treasury hits its statutory debt limit at some point in 2027, as anticipated.

Democrats prioritize Medicaid cuts and ACA subsidies

In a pre-election healthcare policy document, a working group of House Democrats said the party’s priorities would start with repealing the Medicaid cuts in the OBBBA and restoring the Affordable Care Act (ACA) enhanced subsidies. The subsidies expired going into 2026, contributing to a year-over-year enrollment decrease of at least 2.9 million.

Among the other early priorities described in the 84-page document:

• Taking medical debt off credit reports
• Granting relief over physician H-1B visa restrictions
• Blocking the 340B Drug Pricing Program’s upcoming rebate model
• Halting CMS’s ongoing AI-based prior authorization pilot in Medicare

Some Democratic initiatives would be less favorable to hospitals. The working group calls for establishing site-neutral payment for “routine outpatient services,” along with a cap on outlier hospital prices at 200% of Medicare. Protections would be included for rural and safety-net hospitals.

Medicaid changes remain on track despite election results

Given the inability of Democrats to enact autonomous policy changes, providers should not count on policymakers to preserve the status quo in Medicaid.

“It’s important to level-set that changes are likely coming and are likely not going to be delayed or canceled, at least early in 2027, and then that leads to a cascading effect of states needing to make really hard budget decisions,” Allison Orris, partner with Manatt Health, said during a webinar hosted by the firm.

The result could be reductions in provider rates and cuts to optional benefits and perhaps even eligibility, she added.

Bipartisan steps cannot be ruled out. The election results might nudge some Republicans to join Democrats in making OBBBA tweaks or in exercising increased oversight to ensure CMS does not exceed the legislation’s parameters when applying the provisions.

“We’re already starting to get some readout from the states as they’re trying to deploy [OBBBA provisions],” said Miranda Franco, senior policy advisor with Holland & Knight. “I don’t think it’s going to be just the Democrats who are pushing for some of this delay.”

The work requirement likely will take effect on schedule, but states could be granted longer implementation timelines. However, such an accommodation would have to take place during the current Congress, because the work requirement begins Jan. 1 and the new Congress is seated Jan. 3.

Provider advocates may see new openings to push for mitigations of the OBBBA’s tightened limits on provider taxes and state-directed payments, the latter of which are a key revenue source for many hospitals.

ACA marketplace premiums and enrollment rules face scrutiny

The affordability of the ACA marketplaces could be a focus, with a new analysis pinpointing a 13% rise in average benchmark premiums for 2027, following a 26% jump in 2026.

Aside from pushing to restore the enhanced subsidies, Democrats likely will look at a recently issued 2028 proposed rule to implement an H.R. 1 provision negating the availability of subsidies until an enrollee’s demographic and additional information is submitted and confirmed. The rule’s practical upshot would be to limit auto-reenrollment, which comprises a majority of yearly enrollment and thus has been a source of stability in the marketplaces.

Democrats could look to use their oversight authority “in kind of pushing healthcare.gov to be a little bit more consumer-friendly and accessible to folks as they try and navigate this new policy,” said Ellen Montz, managing director with Manatt Health.

How Democrats can be expected to proceed

The biggest area where Democrats can have a unilateral impact on healthcare policy is in oversight of the administration. That could create scrutiny in the form of congressional hearings and investigations for officials such as HHS Secretary Robert F. Kennedy Jr., CMS Administrator Mehmet Oz, MD (especially with regard to OBBBA implementation), and the directors of agencies such as FDA and CDC.

Public-health issues such as vaccine policy, along with examinations of the administration’s most-favored-nation drug pricing policies, likely will be an area of focus in those inquiries, Franco said.

Democrats also figure to draft ambitious legislation, regardless of whether it has a viable chance of becoming law.

There has been increasing chatter about trying to enact Medicare for All, for example. The House working group’s document makes no such endorsement but does call for a public option to be added to the ACA marketplaces or even the broader insurance market.

With Trump in office, such bills likely would be symbolic and potentially a matter of table-setting for the 2029-2030 Congress.

“That policy-development effort is very important,” Barkett said. “It allows the public to see what you as a policymaker are working on and provide you the type of feedback that, if you were to pursue those efforts when you were in control of Washington, would make it more likely to pass because you’ve addressed certain issues that might have otherwise been roadblocks.”

Bipartisan healthcare legislation remains possible

Possible areas of bipartisanship in 2027, according to analysts, include bolstering funding for the Rural Health Transformation Program, expanding site-neutral payment (to cover the costs of prioritized initiatives), reforming Medicare physician payment, updating the No Surprises Act to address concerns about independent dispute resolution, and regulating healthcare AI.

As well, codification and potentially expansion of price transparency provisions are “certainly something we’ve seen bipartisan interest in,” Franco said. “Even with a Democratic sweep, we could continue to see a lot of focus there.”