What The 2022 Midterm Results Might Mean For Health Care – healthaffairs.org

November 13, 2022
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A divided Congress would likely neither dramatically expand nor broadly repeal the Affordable Care Act. However, there are areas of potential bipartisan opportunity—either for the lame duck session or the next Congress—such as telehealth expansion and mental health care access.
With votes continuing to be tallied in several key states and a Senate runoff race in Georgia in early December, it may take days or weeks to know the full results of the 2022 midterm elections. Even so, health care, and especially abortion rights, seems to have been a key factor in many congressional and state races. Based on what we know now, this article takes a first pass at how the results of the midterm elections might impact health policy.
As of this writing, control of the U.S. Senate and the U.S. House of Representatives has not yet been determined. But analysts project that Democrats will maintain narrow control of the Senate. (While this would be the status quo overall, it has significant implications for judicial and executive branch appointments, and it is worth watching to see if there will be changes to the leadership of key health care committees.) The House is predicted to flip from Democratic to Republican control but also with a narrow margin.
Assuming this comes to pass, a divided Congress is nothing new. But it will increase gridlock, require more compromise, and make it harder for Congress to pass new substantive laws.
The election most certainly ends Democrats’ ability to enact sweeping changes like those that were made over the past two years. This includes significant expansions of the Affordable Care Act (ACA) and historic changes to Medicare’s prescription drug benefits. Those two policies appear to be on stable ground. Enhanced marketplace subsidies were extended through the end of 2025, meaning a further extension could be punted to the next Congress. And implementation of the Inflation Reduction Act’s prescription drug policies now sits with the Biden administration. Some Republicans have vowed to repeal those provisions, but lower drug prices for Medicare beneficiaries have not stoked the same level of opposition as the ACA.
Even if those policies are stable, it is unlikely that Congress will adopt or fund other long-sought Democratic health priorities—such as a federal mechanism to close the Medicaid coverage gap, funding for COVID-19 pandemic relief, or a federal law to codify Roe v. Wade. Bills on these issues were passed by the House but failed in the Senate and not included in recent budget reconciliation packages.
If those policies are off the table, what might Republicans focus on? It is not entirely clear. Campaign materials from House Republicans were very general, espousing a commitment to values like personalized care, transparency, and competition. More specific policies are hinted at in materials from various subcommittees of the House’s Healthy Future Task Force. Examples include long-standing Republican priorities such as an expansion of health savings accounts, legislation to authorize association health plans, and a codification of Trump-era transparency rules for hospitals and payers. But it remains unclear which, if any, of these policies might be prioritized by new House and committee leadership.
One thing worth noting is that most, though not all, Republican candidates abandoned prior calls to repeal and replace the ACA. This suggests that broad repeal will not be a focus of the House during the next session. ACA-related policy has not been abandoned altogether: the Healthy Future Task Force makes at least one explicit call to eliminate certain ACA administrative burdens and emphasizes the need to “empower states to approve health insurance plans more suitable to their constituents’ needs by lifting burdensome regulations that require cookie-cutter coverage.” But explicit references to the ACA are otherwise limited, if not nonexistent.
There are also areas of potential bipartisan opportunity—either for the lame duck session or the next Congress. Telehealth expansion and mental health care access are already being worked on by various committees on a bipartisan basis. Congress is being lobbied by providers on a range of Medicare payment cuts that will go into effect next year as well as responses to two recent Supreme Court decisions on 340B payment cuts and access to dialysis services under the Medicare Secondary Payer Act.
What might a Republican-controlled House mean for the Biden administration? The White House and federal agencies will continue their work. But House Republicans will undoubtedly conduct even more oversight—think hearings, letters, and investigations—of the executive branch on health care issues. Republican committee leadership seems eager to focus on various pandemic activities, abortion access, the family glitch rule, and implementation of the new prescription drug policies in the Inflation Reduction Act. Beyond health care, I predict a focus on immigration and the military’s withdrawal from Afghanistan, among other issues.
Beyond the congressional races, it was a big election for health care in the states. I will leave analysis of state legislative races to others, but it is worth highlighting the many health care-related ballot measures that passed (or not) in states across the country as well as highlights from this year’s 36 gubernatorial races.
In the wake of the Supreme Court’s decision in Dobbs, voters in five states chose to protect abortion rights. In California, Michigan, and Vermont, voters approved amendments to each state’s constitution to ensure access to abortion and reproductive health more broadly. In Michigan, for instance, voters agreed to amend the state’s constitution to establish a broad individual right to “reproductive freedom,” including abortion, contraception, miscarriage management, and postpartum care. Abortion can be regulated after fetal viability but includes exceptions for when abortion is medically indicated to protect the life or physical or mental health of the patient.
In Kentucky and Montana, voters rejected ballot initiatives that would have led to even greater restrictions on abortion rights. Kentucky’s measure would have prevented a court from concluding that the Commonwealth’s constitution does, in fact, protect abortion rights even though the state legislature has already banned abortion except in limited circumstances. These results followed an earlier effort in Kansas in August 2022, where voters also rejected a ballot initiative that would have restricted abortion access. Given these successes, it would not be surprising to see even more ballot initiatives on abortion in the 2024 election.  
Beyond abortion, voters in South Dakota approved a ballot measure to expand Medicaid, with about 56 percent support. Voters did so after rejecting an initiative earlier this year that was viewed as a way to try to stymie the expansion ballot effort and that would have imposed a 60 percent voter approval threshold for new ballot measures. An estimated 40,000 people will be eligible when the program begins next summer, and South Dakota will receive the benefit of expansion enhancements adopted in the American Rescue Plan Act. This makes South Dakota the seventh state to expand Medicaid via the ballot box and leaves 11 states without Medicaid expansion.
Voters in Arizona approved what appears to be a novel ballot measure to restrict medical debt collection efforts. The measure, which goes into effect in January 2023, caps interest rates on medical debt and would limit the ability of debt collectors to seize a patient’s personal property and wages. There was significant support for the ballot initiative: 72 percent of voters approved the measure (with 70 percent of votes tallied).
Meanwhile, voters in California approved a ban on flavored tobacco products (including menthol cigarettes), making California the largest state to do so thus far. There is a long history of this initiative that you can read about here, and the tobacco industry has already (within a day) filed a lawsuit to challenge the ballot measure.
Finally, there were mixed results with respect to ballot initiatives on legalization of marijuana. Maryland and Missouri approved the possession and use of marijuana while voters in Arkansas, North Dakota, and South Dakota rejected marijuana-related measures.
Governors—as the head of each state’s executive branch—play a critical role in a wide range of health policies including Medicaid, enforcement of insurance rules, state-based marketplaces, telehealth, abortion access, and more. The scope of legal authority and approach varies by state, and the different approaches taken by governors have been on full display during the COVID-19 pandemic (as just one recent example).
In addition to congressional races and state ballot measures, there were 36 gubernatorial races on November 8, 2022. While much could be said, there are several key takeaways to highlight.
First, Democrats held several contested seats. This included governor’s mansions in Kansas, Maine, Michigan, New York, Pennsylvania, and Wisconsin. Democratic governors in many of the states have played a key role in vetoing bills from more conservative legislatures or have used their executive authority to, say, try to preserve access to abortion services. Democrats will also gain a few governor’s mansions in Maryland and Massachusetts, both states where Republican incumbents were termed out or declined to run again.
Second, the election means there will be a record number of female governors in 2023, with women assuming or retaining governor’s mansions in 12 states (up from the prior record of 9 states in 2004). Incumbent female governors were elected or reelected in Alabama (Kay Ivey), Iowa (Kim Reynolds), Kansas (Laura Kelly), Maine (Janet Mills), Michigan (Gretchen Whitmer), New Mexico (Michelle Lujan Grisham), New York (Kathy Hochul), and South Dakota (Kristi Noem). These incumbents will be joined by newly elected governors in Arkansas (Sarah Huckabee Sanders) and Massachusetts (Maura Healey). These leaders will be joined by female governors in Arizona and Oregon, although it is not yet clear which female candidate will receive the most votes.
Third, there were few other changes in party control, with Republicans and Democrats otherwise maintaining gubernatorial seats in many states. Republican governors were reelected in states that include Florida, Georgia, and Texas. This is likely to mean continued fights over Medicaid waivers, gender-affirming care, and Georgia’s waiver under Section 1332 of the Affordable Care Act. Democratic governors were reelected in states that include California, Colorado, and Illinois.
As of this writing, we are still waiting on the results of key races in Alaska, Arizona, Nevada, and Oregon. The results of these races will be significant for many reasons. But it is worth noting for regular readers that governors in Nevada and Oregon have helped advance more progressive health policies, including public health insurance options and Oregon’s “bridge” health care program. These policies face a more uncertain future under a different administration.
DOI: 10.1377/forefront.20221110.25152

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