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While total vote counts nationwide may not be available for a week or more, we do know voters turned out on Tuesday, November 6, in numbers that appear to have surpassed previous mid-term elections by, perhaps, as many as 30 million votes (versus 2014). While the potential for a true “blue wave” faded early on election night, Democrats did flip the U.S. House of Representatives, while Republicans picked up new seats to maintain control of the U.S. Senate.

One of the issues generating a lot of interest in the mid-terms was health care and the GOP continuing opposition to the Affordable Care Act (ACA). Since the ACA was passed by Congress and signed into law by President Barack Obama in 2010, the Republican-led House of Representatives has acted to repeal all or portions of the health care law during four different congressional sessions (2011-2012, 2013-14, 2015-2016, and 2017-2018). In total, there have been more than 50 votes by the House to update, change, or undo the law.

So, what’s next for the ACA and other health care-related matters? Let’s take a look at some of the midterm results, and what’s ahead for the federal health care law.

ACA/Obamacare/Trumpcare

Congress acted last year to eliminate the financial penalties (in 2019) for those who fail to comply with the ACA’s so-called individual mandate requiring most Americans to have health insurance. Nevertheless, there is still an employer mandate for businesses employing 50 or more Full Time and Full Time Equivalent employees to offer affordable employee health coverage.

There’s also the pending lawsuit, Texas v. United States, which was brought by 20 state attorneys general arguing the ACA is unconstitutional. They say, because the ACA is funded, in part, through taxes on those who do not comply with the individual mandate – and that mandate has been repealed – the entire ACA is invalid.

The states are supported in their argument by the Trump administration, which said in June that it would not defend the lawsuit. That led California Attorney General Xavier Becerra and more than a dozen other state attorneys general to intervene and say they would defend the law, including its protections for those with pre-existing health conditions.

In a prior lawsuit, National Federation of Independent Businesses v. Sebelius (named for then-Secretary of Health & Human Services Secretary Kathleen Sebelius), the U.S. Supreme Court upheld the individual mandate as a tax. Texas and other states say the ACA should be ruled unconstitutional now, since the individual mandate has been repealed (effective in 2019). They argue that if the court agrees (and throws out any part of the ACA), it should void all of the ACA. A ruling could come before year-end; however, that would not immediately end the matter.

Medicaid Expansion

While not an issue in California or Nevada because both states have expanded Medicaid, it was another health care-related topic that drew a lot of attention this year. Initiatives for Medicaid expansion were on the ballot in some unexpected places: Idaho, Nebraska, and Utah. Voters in Montana were asked whether they support the continued funding of Medicaid expansion through a new tax on cigarettes.

While the Montana measure failed (with 55 percent opposing the tobacco tax), voters in the three other states did support the expansion. In Idaho, Medicaid expansion passed by an overwhelming 61-39 percent vote. Nebraskans approved expansion by a slightly slimmer margin: 53-49 percent. Utah’s support level was similar, with 53 percent voting for expansion.

The new states join about three dozen states and the District of Columbia that have adopted Medicaid expansion since 2010. More states could follow because of gubernatorial races in Kansas, Maine, and   Wisconsin, which all elected Democrats.

Drug Pricing, Infrastructure

One area where the new Democrat-controlled House and Republican-led Senate could agree in 2019 is working to reduce prescription drug prices. House Democratic Leader Nancy Pelosi said in October that Democrats want to lower health care costs and reduce the price of prescription drugs. The president has also voiced support for greater prescription pricing controls.

House Democratic Leader Pelosi has also expressed an interest in working collaboratively to rebuild the nation’s infrastructure, which could attract support on both sides of Congress (and on both sides of the aisle), since a presidential election is now less than two years away.

California-Specific Issues

Single-Payer

Californians, expectedly, selected Gavin Newsom as the Golden State’s next governor. While he will be working with a Democrat-controlled state legislature, and he has expressed support for an overhaul in the way California residents get their health coverage, he is not expected to act quickly to make dramatic movements toward a single-payer system.

The week prior to the election, Newsom told attendees at a campaign appearance that a single-payer health care program could be an effective and efficient strategy to deliver universal health coverage; however, he cautioned it might not be achievable at the state level. It is estimated a single-payer system in California could cost $400 billion annually. A legislature-requested study on a possible publicly funded health plan is not expected for two years, giving politicians in Sacramento more time to develop their health care strategy.

Insurance Commissioner

California elected its first new Insurance Commissioner since 2010. (Incumbent Democrat Dave Jones was termed out and could not seek re-election this year.) The 2018 race was unusual because it positioned former Insurance Commissioner Steve Poizner (who ran as a Republican and served in the role from 2007 to 2011) as an independent candidate. He was up against State Senator Ricardo Lara (D-Bell Gardens), who advocated a “health for all” proposal while in the legislature. Although election certification results are still pending, Lara appears to have narrowly defeated Poizner (50.8 percent to 49.2 percent).

Children’s Hospital Construction

Among nearly a dozen statewide ballot measures facing Californians this year, one was to fund hospital construction. Proposition 4 specifically authorizes $1.5 billion in bonds for the construction, expansion, renovation, and equipping of qualifying hospitals that provide children’s health care. The state’s analysis found eight private non-profit hospitals would receive more than 72 percent of the planned funding, while 18 percent would go to five public University of California facilities serving children, and 10 percent would go to about 150 private and public hospitals across the state that deliver eligible children’s health care services.

As reported by The Mercury News (in San Jose), of nearly seven million votes cast on the measure, nearly 61 percent supported the new bonds while 39 percent did not.

Congressional Leadership

With Democrats taking back the House of Representatives, the current House Minority Leader Nancy Pelosi from the San Francisco Bay area could be elected the Majority Leader when the new Congress assembles in 2019. (Pelosi previously held the House Speaker’s gavel from 2007 to 2011.) There is some opposition to Pelosi’s election to the Speaker role, but political analysts appear split as to whether she can win. A Washington Post survey among non-incumbent candidates running for the House before the election found roughly one-third refused to endorse Pelosi or avoided questions about her.

A Look at Nevada

Shift at the Top

For the first time in decades, Nevadans elected a Democratic governor. In a tight race, Clark County Commissioner Steve Sisolak beat Republican Attorney General Adam Laxalt. The margin was approximately 49 percent to 46 percent. More than $23 million was spent in the governor’s race, more than double the amount spent in 2010. Democrat Kate Marshall also won her race for lieutenant governor. That means, for the first time in a quarter-century, Democrats are in control in Carson City. Stay tuned for what that means for health care and insurance legislation.

Congressional Delegation

There was another shift in the team going to Washington, DC, to represent the Silver State. Democrat U.S. Representative Jacky Rosen will be moving across the capitol to take the U.S. Senate seat currently held by Den Heller (winning 50.4 percent to 45.4 percent). She joins Nevada’s other female Senator, Catherine Cortez Masto, also a Democrat, who took office in 2017.

In Nevada’s fourth congressional district, the seat changed hands again – with Democrat Steven Horsford defeating Republican Cresent Hardy in a rematch of their race in 2014. Democrat Susie Lee beat GOP candidate Danny Tarkanian in the race to take over the seat vacated by Jacky Rosen in District 3. Lee won by approximately nine percent. Republican Mark Amodei won re-election in his race in District 2, continuing his service that began in 2011. Democrat Dina Titus won her re-election in District 1; she was first elected in 2012.

Count on Us

We’ll continue to monitor what’s new in health care – nationally, regionally, and locally. To stay up to date, be sure to visit our Newsroom for the latest congressional, carrier, and broker news.