Tagged U.S. Congress

Podcast: KHN’s ‘What The Health?’ Split Decision On Health Care

Voters on Election Day gave control of the U.S. House to the Democrats but kept the U.S. Senate Republican. That will mean Republicans will no longer be able to pursue partisan changes to the Affordable Care Act or Medicare. But it also may mean that not much else will get done that does not have broad bipartisan support.

Then the day after the election, the Trump administration issued rules aimed at pleasing its anti-abortion backers. One would make it easier for employers to exclude birth control as a benefit in their insurance plans. The other would require health plans on the ACA exchanges that offer abortion as a covered service to bill consumers separately for that coverage.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Margot Sanger-Katz of The New York Times and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • The Trump administration’s new contraception coverage rule comes after an earlier, stricter regulation was blocked by federal courts.
  • The insurance bills that the Trump administration is now requiring marketplace plans to send to customers for abortion coverage will be for such a small amount of money that they could become a nuisance and may persuade insurers to give up on the benefit.
  • House Democrats, when they take control in January, say they want to move legislation that will allow Medicare to negotiate drug prices. But fiscal experts say that may not have a big impact on costs unless federal officials are willing to limit the number of drugs that Medicare covers.
  • It appears that both Democrats and Republicans in Congress are interested in doing something to protect consumers from surprise medical bills. The issue, however, may fall to the back of the line given all the more pressing issues that Congress will face.
  • One of the big winners Tuesday was Medicaid. Three states approved expanding their programs, and in several other states new governors are interested in advancing legislation that would expand Medicaid.

Plus, for extra credit, the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: Kaiser Health News’ “Hello? It’s I, Robot, And Have I Got An Insurance Plan For You!” by Barbara Feder Ostrov

Margot Sanger-Katz: Stat News’ “Life Span Has Little to Do With Genes, Analysis of Large Ancestry Database Shows,” by Sharon Begley

Joanne Kenen: The Washington Post’s “How Science Fared in the Midterm Elections,” by Ben Guarino and Sarah Kaplan

Rebecca Adams: The New Yorker’s “Why Doctors Hate Their Computers,” by Atul Gawande

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Midterm Election Boosts Medicaid Expansion, But Challenges Remain

Medicaid — which has been a political football between Washington and state capitols during the past decade — scored big in Tuesday’s election.

Following the vote, nearly 500,000 uninsured adults in five states are poised to gain Medicaid coverage under the Affordable Care Act, advocates estimate. Three deep-red states passed ballot measures expanding their programs and two other states elected governors who have said they will accept expansion bills from their legislatures.

Supporters were so excited by the victories they said they will start planning for more voter referendums in 2020.

Medicaid proponents also were celebrating the Democrats’ takeover of the House, which would impede any Republican efforts to repeal the ACA and make major cuts to the federal-state health insurance program for low-income people.

“Tuesday was huge for the Medicaid program,” said Katherine Howitt, associate director of policy at Community Catalyst, a Boston-based advocacy group. “The overall message is that the electorate does not see this as a Democrat or GOP issue but as an issue of basic fairness, access to care and pocketbook issue. Medicaid is working and is something Americans want to protect.”

But health experts caution that GOP opposition won’t fade away.

David Jones, an assistant professor in the Department of Health Law, Policy and Management at Boston University, said ballot organizers now have a blueprint on how to expand Medicaid in states that have resisted. “I see this as a turning point in ACA politics,” he said. Still, he added‚ “it’s not inevitable.”

Medicaid is the largest government health program, insuring at least 73 million low-income Americans. Half of them are children. To date, 32 states and the District of Columbia have expanded it under the ACA. Before that law, Medicaid was generally limited to children, sometimes their parents, pregnant women and people with disabilities.

The ACA encouraged states to open the program to all Americans earning up to 138 percent of the poverty level ($16,753 for an individual in 2018). The federal government is paying the bulk of the cost: 94 percent this year, but gradually dropping to 90 percent in 2020. States pay the rest.

GOP opposition has left about 4.2 million low-income Americans without coverage in various states.

“It’s not over until it’s over is the story of Medicaid expansion and the Affordable Care Act as the politics never ends and the opportunity for obstruction never ends,” said Jones. “But the trend overall has been to increasing implementation and increasing coverage.”

Montana Fails To Endorse Funding

Two years after President Donald Trump carried Idaho, Nebraska and Utah by double-digit margins with a message that included repeal of the ACA, voters in those states approved the ballot referendums Tuesday. Together, the states have about 300,000 uninsured adults who would be eligible for the program.

In addition, Democrats secured the governor’s offices in Kansas and Maine, which will increase the likelihood those states pursue expansion. Legislatures in both states have previously voted to expand, only to have GOP governors block the bills. Maine voters also passed a referendum in 2017 endorsing expansion, but Republican Gov. Paul LePage again refused to accept it.

Current and incoming Republican governors in Utah and Idaho said they wouldn’t block implementation of the effort if voters approved it. Nebraska Gov. Pete Ricketts said Wednesday he would follow the will of the voters but would not support paying for it with a tax increase.

It wasn’t a clean sweep, however, for Medicaid on Tuesday.

In preliminary results, a ballot issue to fund Montana’s Medicaid expansion — which is already in place and slated to expire next July — was failing. Tobacco companies had mounted a campaign to stop the measure, which would have partially financed the expansion with taxes on tobacco products.

The Montana legislature and the Democratic governor are expected to address the issue in the session that starts in January. No state has reversed its Medicaid expansion, even though GOP governors in Kansas and Arkansas have threatened to do so.

Nearly 100,000 Montana residents have received Medicaid since its expansion, twice as many as expected.

Nancy Ballance, the Republican chairwoman of the Montana House Appropriations Committee who opposed the bill that expanded Medicaid in 2015, said she is confident the state legislature will extend the program past July. But she expects the legislature to put some limits on the program, such as adding an asset test and work requirements.

“There are some people in the state who may not have disabilities but need some help to access coverage,” she said. “I think we can pass something without people having a gap in coverage. … That will be a priority.”

“It was never our intent to simply sunset the expansion and have it go away,” she said. Rather, the legislature put the sunset provision in to revisit the provision to make any changes.

Chris Jacobs, a conservative health policy analyst in Washington, D.C., said the Montana results showed that when voters are given a choice of having to pay for Medicaid expansion through a new tax they were not willing to go along.

But in Utah, voters did agree to fund their state plan by adding 0.15 percent to the state’s sales tax, just over a penny for a $10 purchase.

Fernando Wilson, acting director of the Center for Health Policy at the University of Nebraska Medical Center, said the vote on the state’s ballot question indicated many people wanted to help 80,000 uninsured Nebraskans gain coverage.

“I think it showed there was a clear need for it,” he said. The legislature likely won’t block the expansion, Wilson said, though it may try to add a conservative twist such as adding premiums or other steps.

Sheila Burke, a lecturer in health policy at Harvard Kennedy School, said voters approved Medicaid expansion not just because it would help improve health coverage for their residents but to help stabilize their hospitals, particularly those in rural areas. Hospitals have said this step helps their bottom lines because it cuts down on uninsured patients and uncompensated care.

“The broad population does see the value of Medicaid,” she said. “They saw it as a loss by their states not to accept the federal funds,” she said.

Despite the victories, Burke said, advocates should not assume other states such as Florida, Texas and Tennessee will follow suit.

“I don’t see a radical shift, but it moves us closer,” she said.

‘Fertile Ground’ For More Referendums

If advocates press for more referendums, Florida might be a tempting target. More than 700,000 adults there could become eligible, but the campaign would likely also be very costly.

Jonathan Schleifer, executive director of The Fairness Project, which financed the ballot initiatives in Maine in 2017 and the four states this year, refused to say which states would be targeted next.

The group is funded by the Service Employees International Union-United Healthcare Workers West, a California health care workers union.

“The GOP has been bashing the ACA for nearly a decade, and voters in the reddest states in the country just rejected that message,” Schleifer said. “It’s a repudiation and a tectonic shift in health care in this country.”

“There is fertile ground” for more such ballot votes, said Topher Spiro, vice president for health policy at Center for American Progress, a liberal think tank. “It is clear that public opinion is on the side of Medicaid expansion and the election results merely confirm that.”

“This will build momentum for expansion in other states,” he added.

The election results also could have consequences on efforts by states to implement work requirements for Medicaid enrollees.

New Hampshire and Michigan — which expanded the program but recently won federal approval to add controversial work requirements — could revisit that additional mandate as a result of Democrats winning control over both houses of the legislature in New Hampshire and the governor’s office in Michigan.

House Dems In New Seats Of Power Will Steer Health Policy, Attack Drug Prices

For the first time since passing the Affordable Care Act, Democrats will soon control the House of Representatives and its powerful health committees. But Republicans’ tightened grip on the Senate means those hoping for another round of dramatic, progressive reforms may be disappointed.

Empowered by voters outraged over Republican attempts to chip away at the law’s protections for the sick, Democrats owe much of their midterm takeback to health care issues. And Democratic leaders say they are ready to get back to work, this time training their sights on skyrocketing drug prices, among other policy conundrums, with a majority of House votes and a slate of new committee chairmanships in hand.

In a few weeks, House Democrats will meet to elect their leaders, including several committee chairs who will be responsible for the nation’s health care policy and spending in the coming years. Hill denizens expect those currently serving as the top Democrat on most House committees to ascend to the chairmanships, with few if any members mounting serious challenges.

Those basking in a post-“blue wave” glow would do well to temper their expectations, recalling that the Republican-controlled House had already voted 54 times to unravel some or all of the Affordable Care Act by its fourth birthday in 2014. In most cases, Democrats in the Senate and White House stopped those efforts in their tracks.

With the Senate (and the presidency) remaining under Republican control and even fewer moderate Republicans left in the House after this election, Democrats will struggle to move legislation without Republican support. What they can do is hold hearings, launch investigations and generally unnerve the pharmaceutical industry, among other likely adversaries.

And there’s a chance they could strike a deal with President Donald Trump, whose administration is moving to crack down on drug companies.

Who are the members most likely to wield the gavels? And what will they do with that power? Here’s a look at some of the major committees that influence health policy — and the people who may lead them.

The Committee on Energy and Commerce: Rep. Frank Pallone, New Jersey

Pallone, who has served in the House for 30 years, became the top Democrat on this influential committee in 2015. Should he become chairman, he would be responsible for the broadest health portfolio in the House, which includes Medicaid, public health, insurance and drug safety. This is the committee that marked up the Affordable Care Act in 2009 (when Pallone chaired the health subcommittee) and the House Republican repeal effort in 2017.

Under the Trump administration, Pallone has touted his stewardship of bipartisan legislation reauthorizing the fees charged to manufacturers to review the safety of prescription drugs and medical devices. He has also called for hearings on “mega-mergers” like the proposed merger between CVS and Aetna and worked with other Democrats to counter Republican attempts to undermine the Affordable Care Act.

Unsurprisingly, his influence over health care issues has attracted a lot of money from pharmaceutical companies, health professionals, HMOs and other industry players. By mid-October, Pallone had received more than $945,000 in campaign contributions from  the health sector for this election, according to the Center for Responsive Politics. According to a KHN analysis, nearly $170,000 came from political action committees associated with pharmaceutical companies.

The Committee on Oversight and Government Reform: Rep. Elijah Cummings, Maryland 

Cummings could prove the pharmaceutical industry’s biggest headache come next year. Having served as the committee’s ranking member since 2011 — a post that lacks the chairman’s subpoena power — he has been champing at the bit to hold drugmakers accountable.

Shortly after Trump’s inauguration, Cummings approached him about working together to lower the cost of prescription drugs (to no immediate avail), and he has partnered with other lawmakers to demand information from pharmaceutical companies about their drug pricing strategies. Previewing what a Cummings-led committee might look like, he has even launched his own investigations into drug costs, releasing reports with his findings.

Drugmakers have wasted few campaign contributions on Cummings: He has received just $1,000 from their PACs this election, according to data analysis by KHN.

In a statement to Kaiser Health News, Cummings said Democrats would conduct “credible, responsible oversight” of the Trump administration, adding: “For healthcare, that means investigating skyrocketing prescription drug prices, actions that would threaten protections for people with preexisting health conditions, and efforts to undermine the Medicaid program.” 

The Committee on Ways and Means: Rep. Richard Neal, Massachusetts

Ways and Means oversees Medicare and influences health policy through its jurisdiction over taxes. Though Neal became the top Democrat on this committee in 2017, he has been involved in health care much longer, having played a part in the crafting of both the Affordable Care Act and the failed reform effort under the Clinton administration in 1993.

Facing a primary challenger who touted her support for “Medicare-for-all” in his deep-blue district, Neal denied that he opposes the progressive single-payer proposal. But he also said Democrats should focus on shoring up the Affordable Care Act, particularly its protections for those with preexisting conditions and caps on out-of-pocket expenses. (He won handily.)

The health sector was by far one of the top contributors to Neal’s re-election campaign this year, giving more than $765,000, according to the Center for Responsive Politics. Neal’s district includes the headquarters of several health insurers and other medical companies, which makes him a prime target for campaign contributions.

The Committee on Appropriations: Rep. Nita Lowey, New York

If chosen, Lowey would become the first woman to chair the powerful House Committee on Appropriations, holding the nation’s purse strings.

Like Neal and Pallone, Lowey was first elected to Congress in 1988, and she became the committee’s top Democrat in 2013. She has been a dedicated and effective advocate for investing in biomedical research into major diseases like diabetes and Alzheimer’s, as well as public health programs like pandemic preparedness.

She has also long championed women’s health issues, proving a vocal critic of the Trump administration’s proposed gag rule on Title X funding, among other policies. Watch for her to continue to push back on the administration’s efforts to restrict access to abortion rights.

And on the Senate side, the Committee on Finance: Sen. Chuck Grassley, Iowa?

The rumor mill favors Grassley, the Republican who has served most recently as the chairman of the Senate Committee on the Judiciary, to replace retiring Sen. Orrin Hatch (R-Utah).

Senate Republican leaders have signaled that entitlement programs like Medicare and Medicaid could use trimming and, with Republicans emerging from the midterms with a slightly bigger majority, this committee could have its hands full.

Hatch proved a friend to the pharmaceutical industry, and his war chest reflected that, taking in more than $850,000 in campaign contributions from drugmaker PACs in the past decade alone, according to a Kaiser Health News analysis. But Grassley has taken a more adversarial approach to the industry, working with a Democratic colleague last summer to pressure drug companies to list their prices in direct-to-consumer ads, for instance.

Grassley held the chairmanship from 2003 to 2006, leaving him two more years at the top, should he want it. (Senate Republican chairs may serve for only six years.) But he might choose to stay on as head of the Judiciary Committee, in which case the next chairman may be the next-most-senior Republican: Sen. Mike Crapo of Idaho.

Resultados de las urnas: la salud es importante, pero no crucial, para los votantes

La atención médica resultó importante, pero aparentemente no fue crucial, en las elecciones de medio término del martes 6, en las que los votantes les dieron a los demócratas el control de la Cámara de Representantes, dejaron a los republicanos a cargo del Senado y dijeron sí a la expansión de Medicaid en al menos tres estados controlados por largo tiempo por republicanos.

Al hacerse cargo de la Cámara de Representantes, es poco probable que los demócratas puedan impulsar muchas iniciativas sobre políticas de salud, ya que los republicanos siguen controlando el Senado y la Casa Blanca. Pero podrán frenar, vetando de manera efectiva, los esfuerzos republicanos por derogar la Ley de Cuidado de Salud Asequible (ACA), por convertir al sistema de atención médica de Medicaid para personas de bajos ingresos en un programa de subvención en bloque y por realizar cambios importantes en Medicare.

Un desarrollo probable es una expansión de Medicaid en varios de los 18 estados que hasta ahora no lo expandieron. Los votantes en Utah, Idaho y Nebraska dijeron sí a las medidas de la boleta electoral sobre la expansión.

En Montana, los votantes están decidiendo si la expansión existente debe continuar y si los gastos del estado deben cubrirse mediante el aumento de los impuestos al tabaco. En resultados preliminares, los que están en contra superaron en número a los que están a favor.

Medicaid también podría expandirse en Kansas, donde la candidata demócrata a la gobernación, Laura Kelly, derrotó al secretario de estado del Partido Republicano, Kris Kobach. La legislatura de Kansas había aprobado previamente la expansión de Medicaid, pero fue vetada en 2017 por el ex gobernador republicano Sam Brownback. Kobach no había apoyado la expansión propuesta por ACA.

Y en Maine, en donde los votantes aprobaron la expansión de Medicaid en 2017, pero el gobernador republicano Paul LePage se negó a implementarla, la demócrata Janet Mills resultó ganadora. Mills ha prometido seguir los deseos de los votantes. LePage no se presentó de nuevo.

En las encuestas a boca de urnas, como en muchos sondeos anteriores en 2018, los votantes dijeron que la atención médica, en particular la protección de las personas con condiciones preexistentes, era su principal problema. Pero al final del día, este tema siguió siendo más importante para los demócratas que para los republicanos.

Los que este año instaron a los demócratas a enfatizar la atención médica se atribuyeron los éxitos para retomar el poder en el Congreso. “La carrera por la Cámara de Representantes fue un referéndum sobre la guerra republicana a la atención médica. Lo sabes, lo sé, y los republicanos que intentaron vergonzosamente cubrir su historial real sobre atención médica y perdieron sus asientos lo saben”, dijo Brad Woodhouse, del grupo de defensa Protect Our Care.

Pero el problema no fue suficiente para salvar a algunos de los demócratas del Senado en los estados en los que el presidente Donald Trump ganó en 2016. La senadora Claire McCaskill (demócrata de Montana) fue derrotada por el fiscal general del Partido Republicano, Josh Hawley, quien es uno de los demandantes en un caso judicial clave que busca declarar inconstitucional a la Ley de Cuidado de Salud Asequible. La senadora Heidi Heitkamp (demócrata de Dakota del Norte) y el senador Joe Donnelly (demócrata de Indiana), quienes también hicieron de la atención de salud un tema de campaña, fueron derrotados.

No obstante, el senador Joe Manchin (demócrata de West Virginia) venció al republicano Patrick Morrisey, el procurador general del estado que también es un demandante en la causa que busca cambiar ACA.

La representante Nancy Pelosi (demócrata de California), líder de los demócratas en la Cámara de Representantes, quien estaría primera en la lista para asumir como vocera, dijo a un grupo de partidarios reunidos en Washington, DC para celebrar la victoria, que su grupo haría que la asistencia médica fuera un tema legislativo clave.

“Se trata de frenar el asalto de los republicanos y del líder de la mayoría del Senado, Mitch McConnell, al Medicare, al Medicaid, a la Ley de Cuidado de Salud Asequible, y a la atención médica de 130 millones de estadounidenses que viven con condiciones médicas preexistentes”, enfatizó. Pelosi prometió también que los demócratas ejecutarían “una acción legislativa muy, muy fuerte” para reducir el costo de los medicamentos recetados.

Entre las muchas caras nuevas en la Cámara de Representantes hay al menos una con una experiencia significativa en políticas de salud. La ex Secretaria de Salud y Servicios Sociales, Donna Shalala, quien dirigió el departamento durante los ocho años de la administración Clinton, ganó un asiento abierto en Florida.

Midterm Results Show Health Is Important To Voters But No Magic Bullet

Health care proved important but apparently not pivotal in the 2018 midterm elections on Tuesday as voters gave Democrats control of the U.S. House, left Republicans in charge in the Senate and appeared to order an expansion of Medicaid in at least three states long controlled by Republicans.

In taking over the House, Democrats are unlikely to be able to advance many initiatives when it comes to health policy, given the GOP’s control of the Senate and White House. But they will be able to deliver an effective veto to Republican efforts to repeal the Affordable Care Act, convert the Medicaid health care system for low-income people into a block grant program and make major changes to Medicare.

One likely development is an expansion of Medicaid in several of the 18 states that had so far not offered coverage made available by the Affordable Care Act. Early returns showed voters in Utah, Nebraska and Idaho easily approving ballot measures calling for expansion.

In Montana, voters are deciding if the existing expansion should be continued and the state’s expenses covered by raising tobacco taxes. In preliminary results, opponents outnumbered supporters but key counties were not expected to release their tallies until Wednesday.

Medicaid might also be expanded in Kansas, where Democratic gubernatorial candidate Laura Kelly defeated GOP Secretary of State Kris Kobach. The Kansas legislature had previously passed Medicaid expansion, but it was vetoed in 2017 by former GOP Gov. Sam Brownback. Kobach had not supported the ACA expansion.

And in Maine, where voters approved Medicaid expansion in 2017 but GOP Gov. Paul LePage refused to implement it, Democrat Janet Mills was victorious. She has promised to follow the voters’ wishes. LePage was not running.

In exit polling, as in many earlier surveys in 2018, voters said that health care, particularly preserving protections for people with preexisting conditions, was their top issue. But health care remained more important to Democrats than to Republicans.

Those who urged Democrats to emphasize health care this year took credit for the congressional successes. “The race for the House was a referendum on the Republican war on health care. You know it, I know it, and the Republican incumbents who shamefully tried to cover up their real record on health care and lost their seats know it,” said Brad Woodhouse of the advocacy group Protect Our Care.

But the issue was not enough to save some of the Senate Democrats in states won by President Donald Trump in 2016. Sen. Claire McCaskill (D-Mo.) was defeated by GOP Attorney General Josh Hawley, who is a plaintiff in a key lawsuit seeking to declare the Affordable Care Act unconstitutional. Sens. Heidi Heitkamp (D-N.D.) and Joe Donnelly (D-Ind.), who also campaigned hard on health care, were defeated.

Nonetheless, Sen. Joe Manchin (D-W.Va.) beat Republican Patrick Morrisey, the state’s attorney general who is also a plaintiff in the lawsuit seeking to upend the ACA.

Rep. Nancy Pelosi (D-Calif.), the leader of the House Democrats who is poised to take over as speaker, told supporters gathered in Washington for a victory celebration that her caucus would make health care a key legislative issue.

“It’s about stopping the GOP and [Senate Majority Leader] Mitch McConnell’s assault on Medicare, Medicaid and the Affordable Care Act and the health care of 130 million Americans living with preexisting medical conditions,” she said. She pledged that Democrats would take “very, very strong legislative action” to lower the cost of prescription drugs.

Among the many new faces in the House is at least one with some significant experience in health policy. Former Health and Human Services Secretary Donna Shalala, who ran the department for all eight years of the Clinton administration, won an open seat in Florida.

The Election’s Impact On Health Care: Some Bellwether Races To Watch

Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many.

But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions and state legislatures around the country.

All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen — or not happen — over the next two years.

For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not.

Here are three big health issues that could be dramatically affected by Tuesday’s vote.

1. The Affordable Care Act

Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans and the generic drug approval process, among other things.

Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law.

This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect.

Polls suggest Cramer has a healthy lead in that race, but if Heitkamp pulled off a surprise win, health care might well get some of the credit.

And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care.

It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and two GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general — Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey — are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016.

The attorneys general are running against Democratic incumbents — Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit.

Although Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts.

But in the end the fate of the ACA depends less on an individual race than on which party winds up in control of Congress.

“If Democrats take the House … then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health.

Conservative health care strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday.

“Republicans, if they maintain the majority in the House, will have a margin of a half dozen seats — if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017.

And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there.

2. Medicaid expansion

The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138 percent of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94 percent in 2018, gradually dropping to 90 percent in 2020.

Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid.

McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said.

Four states — Nebraska, Idaho, Utah and Montana — have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs.

In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov. Butch Otter, who is retiring after three terms, endorsed it Tuesday.

But the issue is in play in other states, too. Several non-expansion states have close or closer-than-expected races for governor where the Democrat has made Medicaid expansion a priority.

In Florida, one of the largest states not to have expanded expanded Medicaid, the Republican candidate for governor, former U.S. Rep. Ron DeSantis, opposes expansion. His Democratic opponent, Tallahassee Mayor Andrew Gillum, supports it.

In Georgia, the gubernatorial candidates, Democrat Stacey Abrams and Republican Brian Kemp, also are on opposite sides of the Medicaid expansion debate.

However, the legislatures in both states have opposed the expansion, and it’s not clear if they would be swayed by arguments from a new governor.

3. Medicare

Until recently, Republicans have remained relatively quiet about efforts to change the popular Medicare program for seniors and people with disabilities.

Their new talking point is that proposals to expand the program — such as the often touted “Medicare-for-all,” which an increasing number of Democrats are embracing — could threaten the existing program.

“Medicare is at significant risk of being cut if Democrats take over the House,” Rep. Greg Gianforte (R-Mont.) told the Lee Montana Newspapers. “Medicare-for-all is Medicare for none. It will gut Medicare, end the VA as we know it, and force Montana seniors to the back of the line.”

Gianforte’s Democratic opponent, Kathleen Williams, is proposing another idea popular with Democrats: allowing people age 55 and over to “buy into” Medicare coverage. That race, too, is very tight.

Meanwhile, back in Washington, congressional Republicans are more concerned with how Medicare and other large government social programs are threatening the budget.

“Sooner or later we are going to run out of other people’s money,” said Chris Jacobs.

Senate Majority Leader Mitch McConnell suggested in an Oct. 16 interview with Bloomberg News that entitlement programs like Medicare are “the real driver of the debt by any objective standard,” but that bipartisan cooperation will be needed to address that problem

Republican Jacobs and Democrat McDonough think that’s unlikely any time soon.

“Why would Democrats give that up as an issue heading into 2020?” asked McDonough, especially because Republicans in recent years have been proposing deep cuts to the Medicare program.

Agreed Jacobs, “Trump may not want that to be the centerpiece of a re-election campaign.”

Podcast: KHN’s ‘What The Health?’ Open Enrollment And A Midterm Preview

Nov. 1 marks the start of Open Enrollment for people buying their own coverage for 2019 in most states. Despite the turmoil surrounding the Affordable Care Act, most consumers will have more choices and mostly flat — and in some cases lower — premiums.

What will happen to the health law going forward, however, will depend largely on what happens in the midterm elections Tuesday. Important health decisions will result not just from which party controls the U.S. House and Senate, but who wins governorships and comes to control state legislatures as well.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Margot Sanger-Katz of The New York Times and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • With changes in the ACA marketplace for 2019, it will be very important for consumers to look at the variety of options. Those earning less than 200 percent of the federal poverty level (just under $24,300 for an individual) are likely well served by silver plans on the federal health law’s exchanges. But the choices for benefits and prices are much more complicated for people earning more than that.
  • People who don’t get insurance through work or the government and earn too much to qualify for premium subsidies under the health law might be tempted to try the new, less-expensive short-term plans being touted by the Trump administration. But they should be cautious and consider two major downsides: The plans likely won’t cover preexisting conditions, and the benefits will be skimpier than those of ACA plans. For example, many short-term plans are expected not to cover mental health and maternity services or prescription drugs.
  • Federal officials announced Wednesday that Wisconsin could implement work requirements for some Medicaid enrollees. They also said, however, that the state could not begin drug testing for the enrollees.
  • If Democrats take control of the House or Senate, it’s possible that they could work with President Donald Trump on some specific issues, especially efforts to bring down drug prices or consumer protections against surprise medical bills.
  • Perhaps the biggest change that could come from the election results is an increase in the number of states that expand Medicaid under a provision of the ACA. Seventeen states have not taken that step, but several deep-red states in the West have the question on their ballots, and the outcomes from governors’ races in other states could also lead to expansion.

Rovner also interviews Barbara Feder Ostrov, who wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a California college professor whose skin rash led to a $48,000 bill for allergy skin testing. You can read the story here.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

Plus, for extra credit, the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: The Washington Post and Kaiser Health News’ “For The Disabled, A Doctor’s Visit Can Be Literally An Obstacle Course — And The Laws Can’t Help,” by Rachel Bluth.

Anna Edney: Bloomberg Businessweek’s “Your DNA Is Out There. Do You Want Law Enforcement Using It?” by Drake Bennett and Kristen V Brown.

Margot Sanger-Katz: The Federalist’s “How An Obscure Regulatory Change Could Transform American Health Insurance,” by Christopher Jacobs.

Joanne Kenen: The Atlantic’s “The Harder, Better, Faster, Stronger Language Of Dieting,” by Amanda Mull.

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