Election 2020: Watching the key races for healthcare

The race for the presidency and control of the Senate were undecided on Election Day, leaving big questions about the nation's direction on healthcare policy unanswered.

President Donald Trump won the battleground states of Texas and Florida that Democrats had hoped to flip, and either party's chance for victory runs through key states in the Midwest that have not yet reported final results. Several GOP Senate incumbents held onto their seats, narrowing the potential margin of power for either party. 

Early results signal that Democrats have a possible but narrow path to a trifecta government that could lead to major policy change on healthcare coverage and prescription drug costs. 

President Donald Trump and former Vice President Joe Biden have painted different healthcare visions for the country. Biden has promised to strengthen the Affordable Care Act by increasing subsidies and incentivizing Medicaid expansion, while adding a public insurance option on the exchanges. Trump, on the other hand, supports a lawsuit to strike down the Affordable Care Act and has instead focused on regulatory measures like increasing price transparency and expanding cheaper alternatives to exchange plans. The candidates have also sparred over Trump’s handling of the COVID-19 crisis. 

Flipped Republican to Democrat: Colorado (John Hickenlooper beats Cory Gardner)
Arizona (Mark Kelly beats Martha McSally)

Flipped Democrat to Republican: Alabama (Tommy Tuberville beats Doug Jones)

Several competitive races across the country will determine control of the Senate, and will be key in determining Congress’ healthcare agenda for the next Congress. While the Associated Press called that Democrats flipped Colorado and Arizona's states blue, Republicans regained Alabama's Senate seat. Republicans so far are leading in Iowa, Maine, Montana, North Carolina, South Carolina, Alaska, Kansas and Texas, where they were playing defense. Republicans held 53 seats in the previous Senate, so Democrats would need to gain at least three seats and the White House to flip the chamber. If Democrats take the majority, that would put hospital ally Sen. Chuck Schumer (D-N.Y.) in charge of the Senate.

Divided government in the 116th Congress produced a couple massive COVID-19 stimulus packages early in the pandemic that funneled hundreds of billions of dollars to hospitals and other healthcare providers, but little other bipartisan cooperation on healthcare besides repealing Affordable Care Act taxes on the healthcare industry. Major reforms on lowering prescription drug costs and ending surprise medical bills stalled, and lawmakers failed to reach agreement on another major economic stimulus bill after negotiating for months. The stalemate could continue if the election again results in a divided federal government.

If Democrats manage to squeak out a Senate majority and former Vice President Joe Biden wins the White House, Democrats would have flexibility to move healthcare legislation through a process called budget reconciliation. The maneuver would allow Democrats to pass legislation without GOP support, but would give significant negotiating power to each Democratic senator. The onus would be on potential majority leader Schumer to keep the party united.

House Speaker Nancy Pelosi said on Monday that she hopes to pursue healthcare legislation to shore up the ACA and address COVID-19 through the reconciliation process.

Update: Oklahoma's and California's initiatives failed. Colorado's initiative has yet to be called.

There are three state ballot initiatives to focus on this election cycle: a measure regulating California dialysis clinics; a proposal to give Oklahoma lawmakers more flexibility to fund the state's Medicaid expansion; and a Colorado plan that could impact its ability to draw down federal Medicaid funds.  

California shot down Proposition 23, which would have required chronic-dialysis clinics to have an on-site physician when patients are treated, report data on infections and get permission from the state before closing clinics. The Associated Press called the race Wednesday morning. Dialysis industry giants DaVita and Fresenius claimed it would create arbitrary bureaucratic requirements and cause some clinics to close. But proponents said the measure would improve patients' quality of care.

Oklahomans voted against a plan to take annual funds from a tobacco company settlement and let lawmakers use it to fund Medicaid programs, including the Medicaid expansion voters approved in June. The Associated Press called the race Tuesday night. Republican Gov. Kevin Stitt supported the measure, while the Oklahoma Hospital Association did not take a position. Nearly 59% of voters opposed the measure with 94% of votes counted, per the Oklahoma State Election Board.

Colorado's Proposition 117 would require voters to approve a new state enterprise if it's likely to raise more than $100 million from fees and surcharges within its first five years. Anti-tax groups, including the Koch-backed Americans for Prosperity, claim it's necessary to prevent state lawmakers from skirting a similar rule requiring voter approval for tax increases by relying more on fees. Some healthcare advocates and providers worried Prop 117 could halt the state's hospital provider fee and limit Colorado's ability to drawn down federal Medicaid funds. But experts said the measure wouldn’t affect the hospital provider fee because it only applies to new fees and surcharges.

Significant health policy changes could come from states that can form so-called trifecta governments, with the governor and both the state legislature's chambers from the same party.

North Carolina's GOP-run state Legislature has blocked Democratic Gov. Roy Cooper from expanding Medicaid. But if Cooper wins reelection and Democrats flip the Legislature, it could pave the way for the state to expand Medicaid. Other potential trifectas include Democratic control in Minnesota and Pennsylvania, control by either party in New Hampshire and GOP control in Alaska.

The open Montana governor's race will also be pivotal, as Democratic Gov. Steve Bullock reached his term limit and decided to run for the Senate. Republicans currently control the state Legislature.