Health Care on the Ballot: Assessing the Impact of the Midterm Elections

November 7, 2018

Dean Celia

In an era defined by deep political division, one thing voters seem to agree on is the importance of health care as a political issue. In the most recent Kaiser Family Foundation poll results released in mid-October, more than 70% of respondents said health care is a very important factor in their decision about who to vote for in the 2018 US Congressional election. Furthermore, when asked to choose the single most important issue in their decision about Congress, 3 in every 10 identified health care. It was ranked higher than any other issue in the survey, including the economy and jobs, the typical front-runners in such polls.

In the same poll, 6 in 10 said they trust the Democratic Party to do a better job dealing with women’s access to reproductive health services (61%), maintaining Medicaid expansion (58%), continuing the Affordable Care Act’s (ACA) protections for people with pre-existing conditions (58%), and improving the health of minority populations (58%).

These sentiments among voters were confirmed in exit polls, which showed voters citing health care as the country’s top challenge more than any other issue, including immigration. Perhaps for these reasons, the November 6 election delivered control of the House to Democrats, while Republicans retained control of the Senate. State-level initiatives on the ballot were also poised to have an impact on health care policy.


What do the election results mean for the future of health care in the United States? In the weeks leading up to the midterms, we asked a group of managed care experts to analyze the likely policy reforms and proposals that will be pursued after the election and tell us how they think payers should react. Our panelists include: 

  • Melissa Andel, vice president of health policy, Applied Policy, Washington, DC
  • Gary Owens, MD, president of Gary Owens Associates, Ocean View, DE
  • Arthur Shinn, PharmD, president, Managed Pharmacy Consultants, Palm City, FL
  • Norm Smith, principle payer market research consultant, Philadelphia
  • Barney Spivack, MD, national medical director of Medicare case & condition management at OptumHealth, New York
  • F. Randy Vogenberg, PhD, RPh, principal, Institute for Integrated Healthcare, Greenville, SC

In the political season leading up to the midterm elections, nearly 50% of Democratic candidates’ ads mentioned health care, vs just 31% in 2014. For Republicans, just 21% of candidates’ ads mentioned health care this year vs 44% in 2014. Why do you think that is?

Ms Andel: I think that Republicans wanted to minimize discussions about health care reform because at this moment it is a losing proposition for them. They were able to do away with the most unpopular provision of the Affordable Care Act (ACA), the individual mandate, so all that is left is are parts that people like: community rating and guaranteed issue. Meanwhile, Democrats wanted to use [the possibility of ACA] repeal as a motivating factor for their voters and for independents.

The change in approach probably also has to do with the fact that, in 2014, people were still unsure about “Obamacare” because the main part of the law—the exchanges—had just launched, and was a high-profile failure and fresh in everybody’s minds. It was not a winning issue. Four years later, people have come to like the consumer protections included in the ACA, so now the [Republican party] is on a bit on the defensive.

Dr. Owens: It is no surprise that ACA is better accepted—if not more popular—now vs 4 years ago. It is like other things in life: we don’t quickly adapt to change, but eventually we do. The ACA is not without flaws, but it did bring the ability to obtain coverage to millions of Americans. After more than 4 years of enrollment, we have gotten used to the provisions of the act, and many are benefiting from coverage.

Dr. Spivack: The public is focused not only on the ACA but primarily on ensuring that out-of-pocket costs are lowered—with a primary focus on the cost of pharmaceuticals—and on making sure that coverage for pre-existing conditions is not removed. The [Republican party] has had difficulty fully repealing the ACA in part because of the pre-existing condition provision. Even with control of two branches of the government, they could not get it done. 

Ms Andel: And yet I think there are a number of people who actually believe that the ACA is now fully repealed, and the [Republican party] is happy to continue having them think that way.

Dr Vogenberg: The regulatory changes the Trump administration has made and allowing states more latitude will cause a directional change over the next 2 to 5 years. Remember that ACA reauthorization has to occur along the way, too, so 2020 becomes very important.

With Democrats controlling the House, will single payer proposals such as Medicare for All be given more voice?

Ms Andel: The Democrats may make a run at Medicare for All, but at the end of the day, I think any CBO [Congressional Budget Office] score will torpedo the bill. It will either be pulled or watered down so much that it is unrecognizable. But the House may try a “message” bill to placate the base, just as the Republican House passed ACA repeal more than 50 times [under President Obama].

Dr. Vogenberg: Some form of it may be in play, but nothing significant is likely to happen until the 2020 election.

Dr. Spivack: Medicare for All means different things to different people, and there have been multiple proposals put forward, as analyzed by Kaiser recently. There are differences in eligibility, the size/scope of the public plan, covered benefits and cost sharing, premiums, subsidies, cost containment strategies, and how it works with the current public programs and private sources of coverage. The proposals vary significantly from a single national health insurance program to a public option, to buy-in options and more.

It is very likely that some version of Medicare for All that aims to simplify things, decrease administrative and out of pocket costs, and preserve desired benefits will get much more discussion and consideration. However, improving the existing system—versus starting over—has a better chance of going beyond the discussion phase. Medicare Advantage plans may also be addressed; the different offerings available within private plans may get much more visibility.


Even with Democrats taking the House, it seems that the odds are long for getting universal coverage passed. But what happens in 2020 if a Democrat becomes president? 

Mr Smith: Single payer will certainly be an issue in the 2020 race, and it may advance if a Democrat assumes the presidency. But once the bill is marked up and Congress starts attaching dollars to it, that will put an end to the conversation in all but the most liberal states. For that reason, Medicare for All likely will never get a chance to be voted on. The economics just don't work, as was shown in Vermont 4 years ago. A Medicare buy-in option may fly, and that would release some pressure out of the system. If everyone gets access to a Medicare Advantage plan, there would be controls on costs. The question then becomes, who pays the premium? The employer, taxpayers, or the individual?

Dr. Owens: I don’t think the country is ready for Medicare for All. Medicare struggles with cost now, and if coverage were expanded for all, the infrastructure is just not there to handle the change. Also, the sweeping taxes needed to pay for Medicare for All would be a high hurdle. Plus, how would employers handle this? I do not think workers would want to suddenly be responsible for their [share of] coverage, even if wages are increased to help offset the taxes that would be needed to cover Medicare for All.

Dr Shinn: Medicare for All, in the form proposed by Bernie Sanders when he ran for president, would never become law, in my opinion. The numbers do not add up.

Ms Andel: Keep in mind that single payer has been on the ballot in some form and failed in 3 states in which you would expect it to do well: Colorado, Vermont, and Massachusetts.

If I was advising a 2020 Democratic candidate, I would tell them to focus on fixing some of the problems with ACA: lifting the income cap on premium subsidies and rolling back some of the destabilizing Trump Administration actions.

One problem with Medicare for All is that many of the proposals do not resemble Medicare at all. Bernie Sanders talked about no copayments, no deductibles, but Medicare is full of copayments, deductibles, and caps on benefits. Traditional Medicare has no caps on out-of-pocket expenses, while ACA-compliant plans do have those protections. So, what do politicians mean when they say Medicare for All? I find it interesting that the people who seem to support Medicare for All the most are younger. I wonder if they have had any experience with the actual Medicare benefit themselves.

Mr Smith: Exactly. Many voters don't understand how rich the benefit package is, and how much funding that takes.

Democrats appear ready to fight at the state level to check the Trump Administration’s regulatory changes to the ACA. This would seem to make the 30 state attorney general races pivotal.

Ms Andel: I think so. Democrats are viewing attorney general races as a broad opportunity to open a front against President Trump and Republicans on a number of issues, not just health care. To the extent that the states maintain a lot of power in implementing the ACA and overriding any changes made by Congress, all state-level elections—including governorships and legislative races—are key.

Dr Spivack: I agree. The governorships [are important], as well as control of many of the state legislatures. States can and have created their own payment systems and arrangements distinct from the federal system.

Dr Vogenberg: Republican [control] at the state level makes it easier for them to enforce the Trump Administration’s regulatory changes.

[According to Ballotpedia, Democrats emerged from the midterm election with a net gain in state government trifectas—where one political party holds the governorship, a majority in the state senate, and a majority in the state house in a state's government. Despite this, Republicans still retain a net advantage of at least eight trifectas over Democrats.]

Also at the state level is the potential impact of Texas v. United States, in which 20 Republican state attorneys general and governors are challenging the constitutionality of the ACA now that the individual mandate has been struck down. They argue that the individual mandate cannot be separated from the rest of the law.

Mr Smith: It might be instructive to look at the outcome of the race for Kansas governor. The Republican candidate, Kris Kobach, is part of that lawsuit. The outcome could tell you how voters feel about challenges to the ACA. [Update: Krish Kobach was defeated by Laura Kelly, the Democratic candidate.]

I see it as a losing issue for Republicans, as it would appear to be taking away a benefit, which is never a good look in America!

With Republicans maintaining a legislative majority in the Senate, as well as control of the executive branch, what do you think their health reform proposals will look like in the near future?

Mr Smith: Republicans are now quietly focusing on overturning the pre-existing condition provision. If they maintain a majority, they might become bolder about that. Obviously, people with pre-existing conditions are the main cost drivers in any health care system. If a system of reinsurance can be developed, those people would not be part of the risk pool. They would be placed into a “sick fund” similar to the system Germany has. Getting Congress to appropriate money for such a system is another question.

Dr Owens: It will be very difficult to dismantle the ACA. Much of the inability for actuaries to rate these plans [that existed] in the beginning has gone away. Prices for 2019 actually seem to be plateauing and in some cases lowering a bit. The [Republican party] does not have a suitable replacement. I do agree that some of the less popular aspects of ACA will be modified. But I don’t think Republicans will reinstitute the use of pre-existing conditions to determine coverage.

Ms Andel: I doubt that [the Republican party] will make a run at any more significant changes, because the politics just aren’t there.

Dr Shinn: I agree. The popularity of the ACA among consumers—even those who are part of President Trump’s base—make it next to impossible to fully repeal it.

As for payers, does the playbook they choose after the election change with the outcome of the midterms, or is it business as usual regardless?

Dr Vogenberg: It depends. Payers have their own value proposition to establish based on employer-sponsored plans that are less likely to be impacted by an election outcome. But Medicare is another story. It is becoming more critical to third party payers than ever, and the midterm and 2020 outcomes will likely impact Medicare.

Dr Spivack: Short-term strategies may be impacted by the outcomes of the election, maybe in some states more than others. However, I think that payers’ long-term goals will be the same regardless of the outcome. Focus on ensuring greater consumer value/allegiance and better outcomes while continuing to utilize resources most effectively.

Ms Andel: Payers will keep doing mostly the same as they have been, but I think that has more to do with the Trump Administration calming down a bit on their changes to current policy. Just last week the administration released a statement that praised the fact that premiums were remaining stable and didn’t say the marketplaces were “failing.” The administration and GOP legislators seem to realize that they own this now, and whatever happens, good or bad, will reflect on them.