Tens of millions of Americans will have voted for president, members of the U.S. House and Senate, governors and state legislators by the end of Tuesday in an election that will have a major impact on the future direction of U.S. healthcare.
The closely contested Senate races in a number of states will determine control of the Senate, which could make it easier or harder for the new president to carry out her or his agenda.
The elections surely won't end the nonstop political war over the shape of the U.S. healthcare system that's lasted eight years so far. But the ballot results likely will determine whether the changes driven by the Affordable Care Act continue in the same direction or the system returns to its less-regulated, pre-ACA contours.
Here is a breakdown of where the candidates stand on the health reform law, Medicare, Medicaid and the rising pressure for the White House and Congress to rein in drug prices. A version of this story was originally published in July. Little in their healthcare policy proposals has changed since then.
Hillary Clinton has promised to preserve and expand the ACA's coverage expansions and delivery system reforms. Donald Trump says he wants to repeal them, without offering much detail about what he would put in their place. The fate of the victor's proposals, however, will depend heavily on the partisan makeup of Congress.
The clearest scenario is if Trump wins and his party retains control of both the House and the Senate, which would enable conservatives to repeal or roll back the ACA and implement at least some of the proposals outlined in the GOP party platform and the House Republican leadership white paper on healthcare. But there are divisions even among conservatives over issues such as Medicare restructuring and how to help Americans afford health insurance. And Senate Democrats almost certainly would use their filibuster power to block major ACA changes.
If Clinton wins and Democrats take control of both the Senate and the House—which is considered unlikely—she might be able to push through proposals such as increasing funding for federally qualified community health centers. But Senate Republicans also could use the filibuster to foil her. In the more likely scenario of a Democratic-controlled Senate and a GOP-controlled House, it's not clear how much Clinton could achieve through the legislative process.
That's why some observers predict that a President Trump or a President Clinton would have to use executive powers to put their healthcare policies in place. One possible tool is Section 1332 of the ACA, which lets the federal government grant waivers to states to opt out of the ACA's exchanges and achieve coverage and cost control goals via innovative models.
But the administrative approach carries political and legal risks. The Obama administration has faced a number of court setbacks and infuriated congressional Republicans with its administrative end runs.
Here are some questions and speculations about how the election could affect key health policies: