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Affordable Care Act and Medicaid Expansion May See Benefits from Election Results

Advocate Masthead

ACP executive explains the impact on key health issues

Nov. 16, 2018 (ACP) – Election Day 2018 changed the political landscape in Congress, with Democrats taking over the House of Representatives and Republicans retaining control of the Senate. But what does this mean for physicians and patients?

For perspective, we turned to veteran politics-watcher and longtime health advocate Bob Doherty, senior vice president for governmental affairs and public policy with the American College of Physicians.

Q: What do the election results mean for health care reform?

A: This spells the end of efforts to repeal and replace the Affordable Care Act (ACA). There's no way that would advance in a Democratic-controlled House of Representatives.

However, Congress will have to do something to preserve protections for pre-existing conditions if the courts ultimately rule in favor of a court case that seeks to have the ACA's protections for pre-existing conditions ruled unconstitutional. The case was brought by 20 GOP-led states and supported by the Trump administration.

A decision by a conservative Texas judge is imminent. If he rules for the plaintiffs, as many expect, it will assuredly be appealed to the higher courts. It may be up to the Supreme Court to ultimately make a ruling.

Stripping pre-existing condition protections via a court ruling would be hugely unpopular with the electorate, and almost all of those who won on Election Day promised to protect them, even when some of their own voting records suggest otherwise. But it's by no means certain that a Democratic House, Republican Senate, and President Trump could agree on a path forward to reinstate them.

Still, just about everyone who won election this cycle, including Republicans, promised their voters that pre-existing condition protections will continue. All these politicians would be under enormous pressure to assure they're protected.

Q: What else might happen regarding health care reform?

A: There are legitimate concerns that Affordable Care Act premiums are too high, particularly for those who aren't eligible for subsidies because they earn too much. While there may be interest in both political parties to advance bills to make coverage more affordable, it's hard to see a path forward that could bridge the ideological divide between Republicans and Democrats.

House Democrats will also try to advance bills to overturn the administration's decisions to allow the sale of short-term plans that do not cover essential benefits. But such bills likely would die in the Senate or face a veto from the president. Meanwhile, states that have elected Democrats as governors and to their statehouses may pass legislation on their own to ban or regulate the sale of short-term plans.

Q: How did Medicaid expansion – expanding the number of people eligible for Medicaid – fare at the ballot box?

A: More low-income people will gain coverage from Medicaid expansion, upwards of half a million of them.

Voters approved Medicaid expansion via referenda in three GOP-leaning states: Idaho, Nebraska and Utah. The election of Democratic governors in three other states – Maine, Wisconsin and Kansas – also bode well for expansion. Montana voters, however, voted down a referendum to continue to fund their version of Medicaid expansion via higher tobacco taxes, potentially placing coverage for their residents at risk.

Republicans elected or re-elected to the governorships in other states are unlikely to expand Medicaid, and/or will seek to include work requirements that may make it more difficult for people to qualify.

Still, 37 states and the District of Columbia have now approved Medicaid expansion, so that's great news. It's harder to take away Medicaid expansion once you already have it.

Q: What about drug prices?

A: Prospects for policies to address the high cost of prescription drugs may advance at both the state and federal levels. President Trump suggested that common ground could be found on this issue, and many Democrats newly elected to the governorships and state legislative seats favor policies to require transparency in drug pricing.

Q: ACP favors common-sense policies to reduce gun violence. What will the election mean for that effort?

A: These policies may be advanced in additional states since voters elected candidates to some governorships and legislatures who favor such policies.

Voters in Washington State approved a referendum to advance restrictions on firearms. And NBC's exit poll found that 60 percent of those who voted favored stricter gun control policies, including 46 percent of gun owners, compared with 76 percent of those who don't own firearms.

Democrats are likely to advance gun violence policies in the House, yet it is unlikely that a more conservative Senate and the Trump administration will accept them. On the other hand, the House will almost certainly reject concealed carry reciprocity – requiring states to recognize each other's concealed carry permits – if it's even re-introduced again next year at the gun lobby's bequest. In the current Congress, such legislation passed the GOP-controlled House, but was not taken up by the Senate.

Q: How about women's health?

A: The House will not advance or accept legislation to defund Planned Parenthood and other women's health clinics. It may try to advance bills to overturn the administration's efforts to allow broad “conscience exemptions” to contraception coverage, yet it's hard to imagine those being accepted by the Senate.

With more states under partial or complete Democratic control – governors and statehouses – bills to ensure women's access to reproductive services may fare better in those states than in the past. In other GOP-led states, you may see even more restrictions imposed. For many women, access to necessary services will depend on where they live.

Q: What's next for ACP?

A: We'll continue to push for bipartisan agreement on as many issues as possible, such as on reducing unnecessary administrative tasks imposed on doctors and patients, funding of programs to address the opioid epidemic, making improvements in Medicare's Quality Payment Program, and lowering prescription drug prices.

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Back to the November 16, 2018 issue of ACP Advocate