The outcome of Tuesday's elections could have profound implications for healthcare policy. Most significantly, the outcome of the fight for control of the Senate will shape the tenor and content of the healthcare debate in Washington in the coming months and whether Republicans can damage Obamacare.
Republicans need to pick up six seats to swing control of the Senate, and most political prognosticators believe their chances of succeeding have increased in the closing days of the election cycle. But the final partisan tally might not be known for weeks as runoff elections are a strong possibility in Louisiana and Georgia, where candidates must get at least 50% of the vote to avoid another contest.
And beyond the marquee tussle for control of the Senate, many other electoral fights across the country could have significant consequences for healthcare providers, insurers and patients. An unusually high number of tightly contested gubernatorial contests could alter the dynamics around Medicaid expansion in those states. And ballot measures in several states have healthcare officials worried about the ramifications if they are adopted.
Maine is the state most likely to move forward with expanding Medicaid to households with incomes up to 138% of the federal poverty threshold if Democrat Mike Michaud prevails on Tuesday. But the outcome of the race remains impossible to predict.
The three-way contest took a strange turn last week when independent Eliot Cutler, who has been trailing badly in the polls, essentially blessed his supporters to go with a different candidate if they decide he can't win. That caused some high-profile supporters, most notably independent Sen. Angus King, to throw their support to Michaud.
“Cutler's support is melting away,” said Jim Melcher, a political science professor at the University of Maine at Framingham. “The question is how much?”
But the fate of Medicaid expansion could also hinge on how state legislative races play out on Tuesday. Both the House and Senate are controlled by Democrats, who uniformly support Medicaid expansion, but Melcher believes it's a 50-50 proposition that Republicans will capture the Maine Senate.
“I don't think Republicans taking the state Senate would necessarily rule out Medicaid expansion,” Melcher said. “Not all Republicans in Maine are necessarily opposed to Medicaid expansion. It would certainly make it more difficult.”
Florida could also be in play if Republican-turned-Democrat Charlie Crist reclaims the governor's office. That could lead to nearly 1.4 million people becoming eligible for Medicaid. But Crist would face a Republican-controlled Legislature that's been staunchly opposed to Medicaid expansion.
If Democrats prevail in Wisconsin, Georgia and Kansas, which all have highly competitive gubernatorial contests, they would likely face similar difficulties convincing GOP-controlled legislatures to act on Obamacare's Medicaid expansion.
A couple of states will likely have the opposite dynamic: newly elected Republican governors in states that have already expanded Medicaid. In Arkansas, Republican nominee Asa Hutchinson, who has a solid lead in most polls, has remained coy about whether he would support continuing the state's novel expansion plan, which allows qualifying individuals to purchase private plans with Medicaid funds. Similarly, Arizona opted for Medicaid expansion under Republican Gov. Jan Brewer, but her likely GOP successor, Doug Ducey, has been noncommittal about whether he would support continuing the program.
Caroline Pearson, vice president of Avalere Health, a Washington-based consulting firm, pointed out that it's “incredibly difficult” to take away benefits once they're provided. “New governors in states that previously expanded Medicaid may pursue small changes to Medicaid over time that align with their political philosophy, but they are unlikely to fully repeal the expansion,” Pearson said in an analysis of how the gubernatorial contests could effect Medicaid expansion.
Ballot measures are even more difficult to predict. That's in part because they're not subject to nearly as much polling as competitive electoral contests.
In California, healthcare interests have aggressively fought a ballot measure that would give the state's insurance commissioner the authority to regulate premiums. They've raised more than $50 million, primarily from insurers, to fight the referendum. Officials with Covered California, the state's exchange, have also warned that the referendum could interfere with its ability to implement the Patient Protection and Affordable Care Act by establishing a lengthy appeals process for premium increases.
House Minority Leader Nancy Pelosi has issued similarly dire warnings. “If I wanted to kill the Affordable Care Act, I would do this,” Pelosi told the San Francisco Chronicle's editorial board recently.
Jamie Court, president of Consumer Watchdog, the main organization backing the measure, dismisses this as misguided hyperbole. “These same types of scare tactics were used against Obamacare,” Court said. “I wish (Pelosi) had taken the time to get educated about what this would actually do before she decided to do this.”
Another California ballot measure would raise the limits for medical malpractice awards. The California Medical Association and the California Hospital Association are opposing both referendums.
Polling earlier in the cycle suggested that both measures were headed for passage. But an onslaught of opposition advertising has gutted support. The Field Poll released on Friday found less than a third of likely voters backed either measure.
North Dakota voters will decide on Tuesday whether to adopt a “personhood” amendment to the state's constitution. Supporters of the amendment say it's designed to merely protect the state's restrictions on abortion from judicial interference. But the language of the ballot measure is so vague that medical providers fear it could eliminate in vitro fertilization, invalidate living wills and insert the government into medical decisions.
Robert Wood, an associate professor of public administration at the University of North Dakota, said he expects the outcome to be close. “This is one of the hottest issues on the ballot,” Wood said. “I have no idea which way it's going to go.”
Voters in South Dakota will decide whether to adopt an “any willing provider” requirement for insurers operating in the state. Proponents of the measure argue that it will protect consumers and that it has nothing to with the ACA.
But narrow network plans have emerged as an important means of controlling costs on Obamacare plans and consumers have shown a willingness to sacrifice network breadth in order to save money. A study by researchers Stephen Parente and Robert Book found that the any-willing-provider proposal would drive up premium costs by $3,000 to $5,000 over a decade.
Amy Fried, a political science professor at the University of Maine, points out that any number of dynamics could alter the outcome in tight ballot referendums or electoral contests. Maine, for example, was hit by a major winter storm over the weekend, with some areas buried under nearly two feet of snow. More than 130,000 residents were without power Monday morning. That could make getting to the polls difficult for some voters and have consequences for the gubernatorial contest between Cutler, Michaud and LePage.
Another political wildcard in Maine, Fried said is LePage's showdown with nurse Kaci Hickox over whether she should be quarantined for 21 days after returning from treating Ebola patients in West Africa. “The steps (LePage) took were not supported by the courts. They were not supported by the public health officials,” Fried noted. “But I wouldn't be surprised if some people say he's doing what he needs to do to keep us safe.”
Follow Paul Demko on Twitter: @MHpdemko