Next week, American voters will cast their ballots in national, state, and local elections. Recent polling indicates that a majority of those voters will share at least one concern as they head to the polls: the future of health care.
In the most recent Kaiser Family Foundation poll, 71 percent of voters identified health care as a "very important" factor in their voting, more than they did any other issue. Meanwhile, 30 percent of voters labeled health the "most important" factor affecting their decision—again, more than any other issue.
Voters aren't wrong to be concerned about health care: Next week's mid-term elections could have a profound effect on Americans' access to affordable health insurance. Below, we take a look at the possible effects.
More People Could Get Medicaid
In Idaho, Nebraska, and Utah—all red states that refused to expand Medicaid under the Affordable Care Act—voters will be weighing in on ballot initiatives to expand the program. So far, the initiatives seem to be polling well in all three states.
In six additional states where lawmakers have refused to (fully) expand Medicaid—Florida, Georgia, Wisconsin, Kansas, Maine, and South Dakota—Democratic gubernatorial candidates are currently running even with, or ahead of, the GOP candidates. Democrats are also hopeful about flipping legislative chambers in states across the country.
Democratic wins in these gubernatorial and state legislative races could bring big changes, chief among them Medicaid expansion (although expansion requires approval from legislatures in most states, meaning Democrats will have to do more than flip governor's mansions).
"If more states expand Medicaid—as a result of ballot initiatives, or some of these shifting dynamics, or just simply that a lot of states start to see this as something that's beneficial from a fiscal point of view—we would see a reduction in the number of uninsured in this country and better access," says Sara Collins, vice president of health-care coverage at the Commonwealth Fund. On the flip side, Republican takeovers of gubernatorial or legislative chambers in states that have expanded Medicaid could lead to more restrictions on the program (see: the work requirements that the Trump administration is allowing states to implement).
The effects of successful Medicaid expansions in red states may also have long-lasting consequences for the popularity of the program, and the ACA more broadly. "When you look back to the debate last year, Medicaid really came out a winner. And in the states where Republicans were in control and expanded, the governors didn't want to let go of the federal dollars coming in to their states," says Linda Blumberg, a fellow at the Urban Institute. "If states like Utah, Nebraska, and Idaho move forward with Medicaid expansion, it just further strengthens the number of states that would potentially oppose repeal."
States Could Act to Stabilize the Individual Markets
The possible effects of state-level races on health care extend beyond just Medicaid. States have a great deal of control over the regulation of the private insurance market as well—a fact that's become increasingly relevant during the Trump administration.
For example, in response to the 2017 tax reform bill, which repealed the penalty associated with the individual mandate, New Jersey and Vermont passed state-level mandates to help stabilize their non-group markets. (Several other states have considered such legislation.) Some states have implemented reinsurance programs, which have a strong track record of effectively stabilizing premiums. Others have expanded their outreach, advertising, and enrollment efforts to compensate for the Trump administration's cuts to such services.
States also have the ability to regulate short-term insurance plans and association health plans—two types of insurance that the Trump administration has sought to expand, both of which experts believe undermine the stability of the non-group markets.
"States can take action in their markets to pass bans on those types of plans, or to pass regulations that are more restrictive than the federal rule," Collins says. "We might see more aggressive actions on the part of states to take action."
Or States Could Do Nothing
On the flip side, under the Trump administration, Republican state lawmakers now have more power to undermine the ACA's non-group private insurance markets than they did under the Obama administration. In Iowa, for example, Governor Kim Reynolds quickly approved a meaningful expansion of association health plans in the state after the Trump administration's executive order on the topic.
More broadly, the mid-term elections seem likely to exacerbate a current trend: the fracturing of health care in the country. "Because of the concentration of ACA policy at the state level, we're likely to continue to see a divergence in what people have access to across the country," Collins says. "And so in some states, people will have more affordable premiums, particularly those above the threshold for tax credits, because of the varying policy choices."
Will a Republican House and Senate Try to Repeal the ACA Again?
This is the question that's drawn perhaps the most attention in the mid-terms. If Republicans hold the House of Representatives, and gain just one seat in the Senate, they would in theory have the votes to once again attempt to repeal the ACA. (Senate Majority Leader Mitch McConnell has hinted this would be a possibility.)
Democrats across the country have made this issue central to their campaigns. In two hotly contested Senate races, in West Virginia and Missouri, incumbent Democrats are running against Republican candidates who are currently party to a lawsuit that could eliminate some of the ACA's most popular protections for patients with pre-existing conditions.
ACA repeal would almost certainly result in significant coverage losses. During the first round of the repeal-and-replace debate last summer, the Congressional Budget Office projected coverage losses of over 20 million from the GOP's various repeal-and-replace bills.
Or Is There a Deal to Be Made?
The more likely scenario, however, at least according to current polling, is that Republicans hold the Senate, while Democrats take the House. Dedicated ACA watchers may recall that U.S. Senators Lamar Alexander (R-Tennessee) and Patty Murray (D-Washington) actually held hearings last fall, and reached a tentative agreement, on legislation to stabilize the non-group markets.
Might the Alexander-Murray legislation reappear in a Democratic House? Blumberg, for one, is skeptical. "I think we're most likely to see is a renewed conversation—in terms of bills and hearings and debate and discussion—about what we could be doing to do strengthen these markets, improve affordability for households, and potentially hold down growth in costs over time," she says.