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Thursday, November 6, 2014

Trending: How Will the 2014 Midterm Elections Affect Health Care Advocacy?

Ron Pollack

Executive Director

This week’s midterm and gubernatorial elections shifted the political landscape dramatically. How will these changes affect the work of Families USA and other advocates whose goal is achieving affordable, high-quality health care? They will certainly have some impact, but it is important not to exaggerate their significance. Today, we’re examining the implications for health care advocacy in the states and on Capitol Hill, where the results are still preliminary.

Proposals to weaken the Affordable Care Act

The changes in Congress will lead to an ongoing barrage of federal legislative proposals to undermine the Affordable Care Act (ACA). The first iteration of these efforts will likely be a proposal to completely repeal the historic law—one that will ultimately fail. In the unlikely event that such a proposal does manage to reach the President's desk, it would be vetoed, and won’t secure the two-thirds majority needed to override that veto. 

Thereafter, we can expect the drip, drip, drip of proposals to repeal specific sections of the law. These stand a greater chance of success—they will either be voted on as separate bills or wind up being incorporated in larger bills that have other provisions that the President and Democrats do want to see passed. As a result, we may lose some ground on the employer mandate and provisions applicable to the ACA's financing.

Attention to Medicaid

More significantly, opponents will use fiscal arguments to launch proposals to cut public health programs, especially Medicaid. We’re likely to see efforts to weaken the safety net that Medicaid provides. This may even require advocates to gird the White House so that no legislative compromises incorporate such extreme changes in a program that now covers more than one out of five—and soon one out of four—people in the country, including the poorest of the poor. ‎

Enrollment in the health insurance marketplace remains critical

Support for enrollment in the ACA marketplaces will continue to be important. Much of the success of enrollment will remain in the hands of the Obama Administration, as well as governors in blue states. We may see further reductions in funding for navigator work, which will complicate ‎the potential success of robust enrollment.

Transforming the health care system

Our work to improve private coverage and to transform the health system remains unchanged. At some point, health system reform may very well become the subject of bipartisanship—and advocates need to prepare for that. For now, much of the early work is occurring at the state level, and that won’t change.

Whatever combination of offense and defense lies ahead, our work as health care advocates remains important.‎ Social justice is a never-ending struggle. Whether we play offense or defense (or some combination of both), we must rise to the challenges with all the dedication, creativity, energy, and thoughtfulness we can reasonably muster. We have done so before, and we must continue to do so again and again.

The outlook for health care advocacy in the states: A closer look

The GOP congressional wins mean that states will continue to play a major role in the implementation of the ACA and advances in health reform—including the expansion of Medicaid. Unlike what followed the 2010 elections, when 11 state legislatures switched from Democratic to Republican control, including Alabama for the first time since Reconstruction, these elections will not lead to wholesale turnovers in state policies.

While final totals are not available for all states, at this point, Nevada and New Hampshire are the only states to change the party in control of both chambers of the legislative branch. In the end, Republicans emerged from the election controlling exactly the same number of state governments as they controlled before the election. Democrats lost many chambers and governors, but most of those states now have divided state governments.

Next year, there will also be fewer new governors taking office with fresh agendas to implement. In 2010, 26 new governors took office following the 37 elections. This year, only 11 new executives were elected in the 36 races, and at least four of those will face legislatures controlled by the other party.

More emphasis on basics of governing and fewer bold initiatives

This political landscape will likely mean that states will not see much change in the policies and agendas of the past four years. However, the effort to expand Medicaid in the 23 states that have not yet done so should remain a top priority. To date, nine states with Republican governors who opposed the Affordable Care Act, have supported and succeeded in expanding Medicaid (AZ, IA, MI, ND, NJ, NM, NV, OH, and PA). To succeed, it will be critical that health coverage advocates team up with “strange bedfellow” organizations – groups representing hospitals, physicians, insurers, and local chambers of commerce – that have a business interest in securing Medicaid expansions. Although the gubernatorial elections did not give us a boost in opportunities to expand Medicaid, the fiscal, economic, jobs, and social benefits of the expansion remain a positive incentive for governors and state legislators to approve state expansions.

In 2015, there is likely to be more emphasis on the basics of governing and fewer bold initiatives in the states. Attention will focus on the bread-and-butter budget issues—funding for health care, education, and transportation, to name a few. 

At the same time, there is an opportunity to consider measures that will address health care spending. Efforts around payment and delivery reform that result in savings may garner interest as states grapple with Medicaid budgets. 

The outlook for health care advocacy in Congress: A closer look 

As noted earlier, Republicans may hold another symbolic vote to repeal the health care law, but they will be unable to repeal it. We do expect serious attempts to repeal pieces of the Affordable Care Act, including:

  • the Affordable Care Act’s medical device tax (a small, 2.3 percent excise tax, which helps fund the law, represents $29 billion in revenue over 10 years)
  • the mandate that employers with more than 50 workers provide health insurance to their employees
  • changing the ACA’s definition of a full-time worker from 30 hours to 40 hours a week

Additionally, Republicans have shown their willingness to make significant changes to Medicaid—and we expect more of that. This likely means proposals to cut funding and completely restructure the program through use of a per capita cap. Republicans may also promote changes that weaken the Medicare program. If he is willing, President Obama has the power to veto any and all of these proposals.

Since Republicans have won the Senate majority, it is unlikely that a significant amount of legislative activity will occur during the lame duck session that begins next week. Before December 11, Congress must extend the current fiscal year 2015 funding bill (also known as the continuing resolution). Any additional, significant legislative activity is unlikely to get finished before the end of the year. 

However, Families USA and other health care advocates will continue to push for an extension of funding for CHIP, the Children’s Health Insurance Program, to be included in any must-pass legislation during the lame duck session. It is too early to make a definitive assessment about how the new congressional make-up will affect the funding extension of CHIP. We are confident we can move CHIP funding along on a bipartisan basis, as has historically been the case.

Families USA will keep you informed
In the coming months, we will be monitoring all of these developments, so stay tuned. 

Patrick Willard and Shannon Donahue Attanasio contributed to this article.

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