Since the Great Recession—which officially lasted from December 2007 to June 2009—the economy has been the most important issue for voters.


But due in part to the robust economic recovery of the past two years and a strong emphasis on health care in Democratic Party advertising— 61 percent of pro-Democratic House ads from Sept. 18 to Oct. 15 mentioned health care—health care emerged as the top issue for voters in the 2018 midterm elections.a

Predictions and Results

On Nov. 1, the polling aggregation website FiveThirtyEight gave the Republicans a six in seven chance to maintain their majority in the Senate, and it gave the Democrats a five in six chance to win control of the House.b And both of those predictions came to pass. Based on election night results, the Republicans at a minimum kept their 51-seat majority in the Senate. Depending on the outcome of the remaining extremely tight race in Florida, as well as Mississippi’s Nov. 27 runoff election, the Republican majority in the Senate could expand to as much as 53 seats. In the House, riding voters’ concerns about health care, Democrats gained more than the 23 seats they needed to secure a majority.

As a result, the United States has a divided government, with the Republicans controlling the executive branch and the Democrats controlling one house of the legislative branch. A divided government is quite common—the nation has had one during 20 of the past 30 years. Given this new reality, as well as the acrimonious and highly partisan environment in Washington, D.C., many observers fear the next two years will be characterized by legislative impasses.

Presidential Responses

After a midterm election that transfers control over one or more houses of Congress to the other party, in their post-election news conferences, presidents usually strike a conciliatory tone toward the other party and express a desire to find common ground. For example, in 2010, when the Republicans retook control of the House, gaining 63 seats—the largest House swing since 1948—President Barack Obama described it as a “shellacking,” and in his post-election news conference, he repeatedly expressed a desire to work together with the new House in areas of mutual concern.

Similarly, in his Nov. 7 post-election news conference, President Donald Trump expressed optimism about collaborating with Nancy Pelosi, D-Calif., the likely new Speaker of the House, saying, “I also believe that Nancy Pelosi and I can work together and get a lot of things done.” In terms of areas of common interest, Trump said, “Hopefully, we can all work together next year to continue delivering for the American people, including on economic growth, infrastructure, trade, lowering the cost of prescription drugs. These are some of things that the Democrats do want to work on, and I really believe we’ll be able to do that.”c

Chairmanships

With the Democrats gaining control of the House, they will take over the committee and subcommittee chairmanships. Four of these chairs are most pertinent to health care.  For the House Ways and Means Committee—which is known as the tax-writing committee, providing funds for Medicare, Medicaid, and other programs—Rep. Richard Neal (D-Mass.) is expected to become the chair of the committee, and Rep. Lloyd Doggett (D-Texas) likely will be the chair of the committee’s subcommittee on health. Rep. Frank Pallone (D-N.J.) is in line to chair the regulatory-focused House Energy and Commerce Committee, while Rep. Anna Eshoo (D-Calif.) has expressed interest in chairing the committee’s subcommittee on health.

Neal, Doggett, and Pallone were not among the 123 House Democrats that cosponsored H.R. 676, the Expanded & Improved Medicare for All Act, but Eshoo was.

Medicaid Expansion

Ballot initiatives to expand Medicaid passed in three states: Idaho, with more than 61 percent of the vote, Nebraska, with 53 percent, and Utah, with 54 percent. However, 53 percent of Montana voters rejected that state’s Initiative 185, which would have raised taxes on tobacco products to fund Medicaid expansion beyond its current June 30, 2019, sunset date.

Three gubernatorial elections also had implications for Medicaid expansion. Maine elected its first female governor, Democrat Janet Mills; Kansas elected Democrat Laura Kelly; and Wisconsin Democrat Tony Evers edged incumbent Republican Gov. Scott Walker. Mills, Kelly, and Evers all campaigned in support of the Affordable Care Act (ACA) and the expansion of Medicaid.

Prior to the midterms, 33 states and the District of Columbia had adopted and implemented Medicaid expansion, so with the aforementioned results, the total number of Medicaid expansion states should rise to 38 by July 1, 2019.

Health Policy Forecast for 2019-2020

Despite Trump’s comments regarding working with Democratic leaders in the House, legislative gridlock is a real possibility, if the House Oversight Committee spends the next two years ramping up efforts to investigate the White House and forcing transparency on the president. As Pelosi declared on election night, soon after the major news networks made the call that the Democrats had gained control of the House, “Today is about more than Democrats and Republicans. It is about restoring the Constitution’s checks and balances to the Trump administration.” Trump quickly responded, saying on Twitter, “If the Democrats think they are going to waste taxpayer money investigating us at the House level, then we will likewise be forced to consider investigating them for all of the leaks of classified information, and much else, at the Senate level. Two can play that game!”d

If the investigations into the Trump administration do not completely poison the well of bipartisanship, a number of health policy developments could occur the next couple of years. The most likely ones are preserving preexisting condition protections, pursuing additional responses to the opioid crisis (building on the overwhelming passage earlier this year of H.R. 6, The SUPPORT for Patients and Communities Act), and reining in prescription drug prices, along with acting in response to the continued growing popularity of Medicare Advantage among the nation’s seniors and commercial health insurers.

The polar extremes of a complete repeal of the ACA on one end and Medicare for All on the other end are clearly off the table for now, though Medicare for All will undoubtedly be a cause célèbre for 2020 Democratic presidential candidates. 


Ken Perez is vice president of healthcare policy, Omnicell, Inc., Mountain View, Calif., and a member of HFMA’s Northern California Chapter.

Footnotes

a. Edwards, H.S., “Forget ‘Repeal and Replace.’ The One Issue Unifying Americans Is Affordable Health Care,” Time, Nov. 1, 2018.

b. FiveThirtyEight, “Forecasting the Race for the Senate,” updated Nov. 6, 2018; FiveThirtyEight, “Forecasting the Race for the House,” updated Nov. 6, 2018.

c. Transcript, “Trump’s Contentious Press Conference About Midterm Elections,” Chicago Sun-Times, Nov. 8, 2018.

d. Tracy, A., “Congress is Going to Force Transparency on This President: House Democrats Prepare to Turn Trump’s Life Upside Down,” Vanity Fair, Nov. 8, 2018. 

Publication Date: Friday, November 16, 2018