Repeal-and-replace is dead, buried, gone. Medicaid expansion passed everywhere it was on the ballot. The Affordable Care Act, with its core premise that health insurance is the right of every citizen, lives.
Divided government ensures the past decade's progress toward achieving universal health insurance will not be reversed, at least not in the next two years. The Democrats who won in suburban swing districts found a winning formula in pledging to protect people with pre-existing conditions while preserving and extending Medicaid to low-income families earning up to 138% of the poverty line.
By the end of the campaign, even Republicans were running ads claiming they wouldn't allow discriminatory insurance underwriting. Perhaps they thought their constituents would forget their actual votes to remove those protections. Voters wisely cast their ballots based on what they did, not what they said.
Grassroots campaigns in Idaho, Nebraska and Utah—deep red states that had repeatedly refused to expand Medicaid—succeeded in winning at the ballot box what they couldn't get done in their statehouses. Unfortunately, Montana, inundated with Big Tobacco money, rejected a cigarette tax, so funding for its existing expansion remains in doubt.
New governors in some of the 15 remaining states that haven't expanded Medicaid should make a difference. In Kansas, for instance, where Republicans in the Legislature passed expansion because it helps rural hospitals, newly elected Laura Kelly will support what former Gov. Sam Brownback vetoed and her opponent opposed.
Unfortunately, the legislative climate will likely remain hostile to Medicaid expansion in the Sunbelt states with the largest uninsured populations—Texas, Florida and Georgia—although recounts are possible in the latter two. Looking ahead to the 2020 election, expansion advocates in those states might want to take a page from the direct democracy playbook that proved successful this year in expanding Medicaid in smaller states.
While the ACA will no longer be under legislative assault in Washington, the Trump administration's effort to undermine it through rulemaking will proceed apace. That's one area where it's crucial that the Democrats in the House exercise their new oversight powers.
The incoming chair of the House Oversight and Government Reform Committee, likely Rep. Elijah Cummings (D-Md.), should subpoena CMS Administrator Seema Verma to produce records that justify its approval of waivers allowing Medicaid work requirements, a move that Rep. Trey Goudy (R-S.C.) resisted as chair. If the waivers are shown to have reduced enrollment, it lays the groundwork for ending these needlessly punitive experiments.
Democratic chairs of the Energy and Commerce Committee and Ways and Means health subcommittees should also launch investigations into the administration's efforts to limit individual enrollment through the exchanges. Has ending cost-sharing subsidies raised rates? What impact has sharply reducing outreach efforts had on enrollment? Will short-term plans with limited benefits lead to more uncompensated care and higher rates on everyone else?
A steady stream of headlines from hearings on these issues would educate Americans about why health insurance needs to be universal, comprehensive and well-regulated if rates on the exchanges are going to be affordable.
During the campaign, neither side addressed the root causes of high out-of-pocket spending, which is a growing problem for many families. Will the newly empowered Democrats be able to find common ground with the Trump administration and the enlarged Republican majority in the Senate to do something about high drug co-pays and deductibles, and surprise bills for out-of-network charges?
Given the powerful special interests invested in preserving the status quo, the most likely scenario over the next two years is inaction on each of those issues. This year's election offered no guidance toward a politically acceptable solution to healthcare's core problem: its unacceptably high cost
