I have decided to join what seems to be a national pastime: predicting in January what will happen in health policy during the course of the year. This year, such forecasting may be easier than is typical; not much health-related legislation (or any other substantive legislation) is likely to pass in 2018, partly because it is a midterm election year for Congressional seats, and partly because the balance of Republican vs Democrat votes in Senate has shifted from 52 to 48 to an even closer 51 to 49 split after Doug Jones (D, Alabama) won a seat in Senate in December.
The focus on the 2018 election by both parties really began in 2016, after the unexpected Republican sweep of the presidency and both houses of Congress in 2016 and Democratic victories in the governors’ races in New Jersey and Virginia and Sen Jones’ victory in Alabama in 2017. With all of the House seats, one-third of the Senate seats and 36 of the governors up for reelection, Democrats are hoping to capitalize on President Trump’s high disapproval rating (about 56%, according to the end-of-the-year average of RealClear Politics polling) and assume the majority in either or both chambers of Congress and claim some of the gubernatorial races.
The majority party in the House typically loses 25 seats (median loss of 22); if Republicans lose at least 24 seats, they would lose control of the House. Backlash against the President’s party in 2006, 2010, and 2014 led to much greater losses—the largest being 63 seats lost by Democrats in 2010. Because the party of a president with low approval ratings usually suffers large mid-term losses, control of the House could indeed switch. Control of the closely divided Senate could change with a small number of Republican losses, but Republicans will be aided by having only 9 Republican-held seats up for a vote vs 25 seats for Democrats.
What this means for health policy is that there will be little inclination towards bipartisan support for passing legislation, even compared with 2017, when most legislation passed with only Republican support. Various attempts at “repeal and replace” of the Affordable Care Act (ACA) failed to get through the narrowly divided Senate after the House passed the American Health Care Act. The House may raise the issue again, although it is very difficult to imagine the Senate being more successful at passing a replacement bill for the ACA with one fewer Republican vote than they had during 2017. Senate Majority Leader Mitch McConnell (R, Kentucky) has indicated he plans to focus on other issues in 2018.
There are a few “must pass” bills that may include health legislation. Congress must pass a long-term spending bill by January 19 to keep the government open. Democrats will need to provide some support in the Senate, because it will require 60 votes for passage, and perhaps in the House, as well. The short-term spending bill passed in late December included funding through March for the Children’s Health Insurance Program (CHIP), which provides financial support to insure children who are above the Medicaid eligibility level. CHIP has a bipartisan history and continues to be supported by both parties, but there has been no agreement on how to fund the extension. Stand-alone legislation providing longer-term funding for CHIP could pass this spring, or other legislation—but perhaps not the January spending bill—could include funding for CHIP.
Democrats have been less vocal in calling for legislation that would include funding for the ACA subsidies or for cost-sharing reductions (CSRs) that reduce copays and deductibles for lower-income people who get insurance through the ACA marketplaces. Senate Majority Leader McConnell had promised Sen Susan Collins (R, Maine) votes on 2 proposals intended to help stabilize insurance premiums, in exchange for her support of the tax bill. It is not clear, however, whether either bill would get enough support in the House for passage unless House Democrats decided to support them. It is also not clear how much they are needed, given the surprisingly robust enrollment rate in the ACA marketplaces reported for 2018, despite a shorter enrollment period and reduced funding for outreach.
The likely absence of new health legislation in 2018 does not mean that no change is possible. The Trump administration has indicated interest in supporting requests from the states for Medicaid or 1332 waivers. Medicaid waivers have provided substantial opportunities to states in the past for experimentation, and the Trump administration has indicated an interest in promoting even more change for Medicaid in the future—particularly for waivers relating to work requirements or drug testing. As for 1332 waivers, which allow experimentation with how subsidy money is used in the ACA, only 4 were provided in 2017, but that may change substantially in the future. The administration is also likely to continue using rule-making to change policy, as was done recently to broaden eligibility for membership in association health plans.
Some Republicans, including House Speaker Paul Ryan (R, Wisconsin), have indicated an interest in reviewing (and altering) the medical entitlement programs, Medicare and Medicaid. While Medicare is fiscally unsustainable in its current form and will need to be modified within the next decade to better align the benefits promised and the program’s financing, this will require a bipartisan effort—something that is not going to happen during the year of a mid-term election in which the minority party hopes to make substantial gains.
Medicaid may also be the subject of review and reform at some future time to address the different matching rates between the base Medicaid program, the Children’s Health Insurance Program, and expanded Medicaid and also to address the states’ use (or misuse) of their portion of the Medicaid matching funds (a topic I discussed in the JAMA Forum in March 2017 and May 2017). What is not going to happen is legislation that produces a substantial reduction in federal government spending on Medicaid. The pushback from Republicans in the Senate in 2017 made that point very clearly.
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Gail Wilensky, PhD Gail Wilensky, PhD, is an economist and Senior Fellow at Project HOPE, an international health foundation. Dr Wilensky previously directed the Medicare and Medicaid programs and served in the White House as a senior adviser on health and welfare...