Five Ways the Midterms Changed Healthcare

Marcia Frellick

November 08, 2018

Tuesday's midterm elections resulted in changes in leadership and passage or denial of ballot initiatives that have implications for healthcare nationwide.

Here are five of the major areas affected.

1. Medicaid

The red states of Nebraska, Idaho, and Utah approved Medicaid expansion.

Bob Laszewski, president of Health Policy and Strategy Associates, told Medscape Medical News that "these are middle America, heart-of-Republican country states, so it's a pretty clear indication that even in the reddest states, the voters want the expansion of Medicaid."

New Democratic governors were elected in the nonexpansion states of Maine, Kansas, and Wisconsin, increasing the odds of expansion in those states. Montana voted down a bill that would continue Medicaid coverage after 2019, funded by a cigarette tax, which jeopardizes its future.

In Montana, Laszewski said, "It's not clear if they were against Medicaid or against particular funding."

Joan Alker, MPhil, research professor at the Georgetown University McCourt School of Public Policy in Washington, DC, told Medscape Medical News, "It was a very good night for Medicaid."

"Most importantly, the huge, draconian cuts that the last Congress proposed to the Medicaid program will not happen in the next 2 years," she said.

The results may also have implications for Medicaid work requirements.

Wisconsin's new governor is not in favor of work requirements for Medicaid whereas the former governor was. Republican governors in New Hampshire and Arkansas are in favor of the requirements.

Florida and Texas are the two biggest nonexpansion states, and because Democrats did not win a tight gubernatorial race in Florida, that state likely will continue to oppose expansion. Georgia's gubernatorial race is yet to be decided: the Democrat wants to expand Medicaid, the Republican doesn't.

2. Affordable Care Act

With the House of Representatives now controlled by Democrats — and with Republicans still short of the 60 votes needed in the Senate to override a filibuster — efforts to repeal the Affordable Care Act (ACA) likely will stall.

"We've gone from a situation where the repeal of the ACA was an organizing principle for the Republican Party for many years to a situation now where that likely cost them the House," Alker said. "For the next 2 years anyway, we won't see efforts to repeal the ACA and cut Medicaid significantly. That's really an amazing trajectory."

She said she has worked in healthcare for two decades and the concern for healthcare coverage "is at an all-time high."

Lack of change doesn't mean the ACA shouldn't change, Laszewski said. "[The ACA] needs to be fixed and it won't be touched because the Democrats and Republicans aren't going to be able to agree on any fixes."

"I think Republicans really misunderstood the anti-Obamacare feelings prior to 2017," Laszewski said. "Republicans thought they had a carte blanche mandate to get rid of Obamacare and that just wasn't the case. Obamacare has a lot of problems and people know that, but Obamacare did three things: it had pre-existing condition reforms, it had subsidies for those who couldn't afford insurance premiums in the exchanges, and it had Medicaid expansion, so it had health insurance security in it."

Democrats also misunderstand what voters think about Obamacare, he said.

"You've got Democrats saying Obamacare is safe and secure now because the electorate has supported it. I think that's baloney. What's safe and secure are the health insurance security elements that voters never really wanted to get rid of. It doesn't say that Obamacare doesn't still have a pile of problems. This is not about the ACA. It's about health insurance security."

Short-term insurance plans will also likely come under heightened scrutiny with Democratic control of the House.

MarketWatch quoted Scott Flanders, chief executive officer of eHealth, an online health insurance marketplace for both traditional and short-term plans, as saying, "We can expect a Democratic house to attack those plans in the same way that the Republicans attacked the ACA for the last 6 years."

3. Marijuana

Utah and Missouri legalized medical marijuana; North Dakota voted against it.

Michigan approved a ballot measure to legalize cannabis, the first Midwestern state to do so, for recreational purposes. The measure will allow adults age 21 years and older to possess, use, and grow small amounts.

Illinois, Minnesota, Michigan, New Mexico, Wisconsin, and New York elected governors who have expressed support or interest in marijuana legalization.

"The days of adults being afraid of marijuana are over. It's just a question now about how quickly states pass liberalization laws," Laszewski said.

4. Abortion

Two states approved ballot measures to limit or ban access to abortion.

Alabama became the first state in the United States to add a "personhood clause" to its constitution, recognizing "the rights of unborn children, including the right to life."

In West Virginia, voters approved eliminating any abortion rights protections from the state constitution, cutting Medicaid funding for abortions, and setting a jail sentence of 3 to 10 years for women who get the procedure and anyone who performs it.

The measures set the stage for legal challenges if Roe vs Wade is overturned.

Conversely, Oregon voters defeated a measure that would have restricted public funding and insurance coverage for abortion.

5. Nurse Staffing

In Massachusetts, voters defeated a nurses' union initiative that would have capped the number of patients assigned to individual nurses.

Laszewski and Alker have reported no relevant financial relationships.

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