During this 2018 midterm election campaign season, candidates and pundits have discussed what this election could mean for health care and health policy. The House and Senate elections at the federal level could result in the reintroduction of Affordable Care Act repeal and replace efforts, or the beginning of a conversation about a single payer solution. Federal elections are clearly important, but state elections are also extremely crucial to the future of health care due to the current gridlock in Congress. Governors, state legislatures, Attorneys General, and ballot initiatives have a great deal of power to determine access to and affordability of health care in a state. In this blog, we outline what’s at stake for health care in the 2018 state level races.
Why watch: Some of the hottest health care issues in play in the 36 governor’s races across the country are access, affordability, and addressing addiction. Furthermore, although Medicaid as an issue is not dominating the average voter’s attention, it is a critical issue for both proponents and opponents. Each state has more flexibility than under the previous administration to determine rules and alter the structure of Medicaid for their citizens.
What’s at stake: Five states are a toss-up or only slightly leaning in one direction (NV, KS, WI, OH, GA) as depicted in the map below. The outcome of these five states and all of the Governor races could have a profound impact on health care access, affordability, and strategies for addressing pressing issues like addiction.
Access: Medicaid expansion is a major issue in many gubernatorial races. Democratic candidates generally support Medicaid expansion while Republican candidates largely oppose expansion, or support expansion with eligibility restrictions like work requirements. Candidates in toss-up/flip states, including Georgia, Florida, Maine, and Kansas have been outspoken about their position on Medicaid expansion. If all four of these states elect Democratic governors who then expand Medicaid, the combined reduction in the uninsured would be around 1,324,000 people.
In addition to the question of whether to expand access to Medicaid, the option to apply additional rules regarding Medicaid eligibility are now on the table due to recent action from the federal government. Since January 2018, states have been invited to apply for waivers to impose work requirements on Medicaid eligibility. Fifteen states have since applied, ten of which are holding Governor’s races (see map below). Expect this issue to largely play out along party lines, with Republicans in support of eligibility restrictions.
Because affordability and addressing the opioid epidemic are priority issues on both sides of the aisle, it will come down to candidates’ strategies to tackle these issues.
Affordability: In terms of affordable coverage options, several Republican candidates are turning to the market and campaigning for lower cost insurance plan types like association health plans and short-terms plans. However, short-term plans don’t guarantee protections for pre-existing conditions, unless states choose to regulate the plans. Insurance Commissioners are generally responsible for these regulations and are appointed by the Governor in many states.
In terms of affordable prescription drugs, several candidates on both sides of the aisle are turning to transparency and campaigning for drug price disclosure and notification of spikes in pricing by pharmaceutical companies.
Addressing Addiction: The Governor’s race in Oregon highlights different strategies that candidates are leaning on to address addiction: The Democratic incumbent stresses increasing access to naloxone, a drug that reverses opioid overdoses, whereas the Republican challenger is focusing on medication assisted treatment and peer counseling. One strategy that we are not likely to see deployed by Republican candidates is Medicaid expansion to improve access to addiction treatment – but expect to see this strategy as a component of Democratic candidates’ platforms.
Why Watch: Republicans currently control 67 of the 99 state legislative chambers, control both chambers in 32 states, and hold the Governor and both chambers in 25 states. In this election, 87 chambers will be on the ballot and there are around 22 battle ground chambers.
What’s at Stake: Some of the battle ground states have not expanded Medicaid, including Maine, Wisconsin, and Florida. If the Governor and state legislatures both flip Democratic, then the road to Medicaid expansion would be viable. Because Florida has the third highest percentage of uninsured adults in the United States at 20.1%, Medicaid is a major issue in the race, with 65% of Florida voters saying that they support expansion. Virginia is a great example of a state where a single election resulted in enough seat changes to open the path to Medicaid expansion. In the 2017 election, Republicans lost 15 House of Delegates seats, bringing their majority down from 66 to 51 out of 100 total seats. Paired with a win by the now Democratic Governor, that shift allowed Virginia to expand Medicaid to an additional 400,000 Virginia residents.
Beyond Medicaid expansion, state legislatures have other important controls over health care in their states, such as the ability to protect certain provisions of the ACA, impose individual mandates, restrict low cost/poor value health plans, and approve Medicaid waivers (e.g., eligibility restrictions and work requirements). Additionally, many state legislatures are responsible for redistricting, and will be in office for the redistricting associated with the 2020 census. This could impact the competitiveness of numerous districts for many years, which could in turn impact long term health policy, depending on how the districts are drawn and which party they favor.
Medicaid Expansion Through Voter-Sponsored Initiatives
Why Watch: States first expanded Medicaid under the Affordable Care Act less than five years ago, but the arduous twists and turns of the ensuing political battles have had the feel of an ages-long conflict—one for which the 2018 elections present an intriguing development. Those who did not expand initially have faced intense pressure from advocates and constituents who seek to use the federal funds allocated by the law to increase health insurance coverage in their states.
What’s at Stake: The 2018 elections mark a new development in these long-fought battles, and a new tack from expansion advocates, as expansion is usually done at the behest of the governor’s office. Three deep-red states: Idaho, Utah and Nebraska, have placed voter-sponsored Medicaid expansion initiatives onto their ballots. If the ballot initiatives passed in these three states, combined they would reduce the number of uninsured individuals by roughly 190,000. Additionally, Montana has a ballot initiative that would keep Medicaid expansion by reversing the planned sunsetting of the expansion program in 2019 and raising tobacco taxes to fund the state’s share of the expansion costs.
Idaho, Utah or Nebraska would not be the first state to pass a Medicaid expansion law through voter-sponsored initiative. In November of last year, 59% of Maine’s voters elected to pass Medicaid expansion, after organizers collected the required 98,492 signatures to get the issue on the ballot. Ever determined to resist expansion, Maine governor Paul LePage has refused to implement the law.
Despite the Maine expansion stalling, advocates in these three states are forging ahead with an optimism that belies their states’ conservative voting history (Trump won Idaho by 32 points). And they have good reason to do so—state polling reveals strong support for expanding coverage despite a pervasive “small government” zeitgeist. When it comes down to it, people of all political stripes want higher levels of coverage for their fellow citizens. And they want the federal tax dollars they pay to circulate back to their states, instead of flowing to others.
Wyoming, South Dakota, Oklahoma and Missouri have not yet expanded Medicaid, but allow voter-sponsored initiatives under state law. On November 7th, when we have a better sense of whether such initiatives can succeed in red states, we’ll be turning our eye to them to see what happens next.
Why Watch: State Attorneys General (AGs) jurisdiction allows them to contest what is passed down by the federal government if viewed as potentially harmful to their state’s residents, as we’ve seen in some recent highly visible cases (such as the constitutionality of the individual mandate of the Affordable Care Act in Texas v. United States). If Republican AGs keep their positions or if new Republican AGs win positions, we expect to continue to see AGs band together to challenge the Obama administration’s health care policy items. If the reverse happens and we see more Democratic AGs, we are likely to see challenges to the current administration’s health care policy agenda. In fact, AG office results may be some of the most important of the 2018 election for health care law.
What’s at Stake: Thirty AG offices are up for election in 2018. The Republican Party’s overall hold on AG offices is less dominant than its hold on governors’ mansions: 27 AG offices are Republican-controlled whereas 22 AG offices are Democrat-controlled. Of the 30 contested offices, eight are predicted most likely to flip, with 7 of the 8 flipping from Republican to Democrat (AZ, CO, FL, MI, NV, OH, WI) and only 1 flipping from Democrat to Republican (MN). Wisconsin is a good example of an influential race for the future of health care laws. Wisconsin, under the guidance of the current Republican AG, was one leading states on the Texas v. United States case that threatens to undermine the Affordable Care Act.
How did the AG races become so exciting? Much of the strength of the Democrats’ campaign is contained in the message that Republicans are threatening voters’ access to health care by supporting the Trump administration’s move to remove coverage protections for individuals with pre-existing conditions. And the campaign dollars have followed: both sides of the political aisle expect record-breaking fundraising amounts to flood these races.