In the Voting Booth, Healthcare a Factor That Could Determine Race Outcomes

November 7, 2018

With a preference for healthcare as the number one issue among Democrats and independents, the 2018 midterm election is being called a referendum on healthcare issues. But at the federal level, will healthcare become a gridlocked issue for the next 2 years of President Trump's first term?

With a preference for healthcare as the number one issue among Democrats and independents, the 2018 midterm election is being called a referendum on healthcare issues. But at the federal level, will healthcare become a gridlocked issue for the next 2 years of President Trump's first term?

FiveThirtyEight is predicting as much, seeing the Democrats taking the House of Representatives and Republicans hanging onto control of the Senate, possibly adding a seat to their current majority.

Healthcare, especially issues related to the Affordable Care Act (ACA), is "devolving to the states," said Benjamin Isgur, who heads PwC's Health Research Institute, in an interview with The American Journal of Managed Care®.

Aside from individual candidates, Medicaid is on the ballot in 4 states. Medicaid provides healthcare to about 76 million low-income individuals, or about 1 in 5 Americans. The ACA allowed states to expand Medicaid eligibility to nonelderly adults with incomes up to 138% of the federal poverty level.

Although the expansion was originally intended to be enacted nationwide, in 2012 the Supreme Court ruled that states could opt out of it. Despite failed efforts by the Trump administration to repeal the ACA outright in 2017, the attempt actually wound up increasing the popularity of Medicaid.

In 3 states today, voters in Idaho, Nebraska, and Utah will decide whether their states will adopt the expansion. Montana voters will choose whether to extend Medicaid expansion beyond 2019. If the measures are approved, those states would join the 34 that have expanded the program.

Here’s a look at some races where healthcare concerns could make a difference in the outcome:

Governor’s Races

There are 14 tight governor’s races where the outcome could determine healthcare changes in those states, whether the topic is about Medicaid, protecting the pre-existing conditions of the ACA, or other possible changes, according to the Kaiser Family Foundation.

In Florida, Democrat Andrew Gillum, the progressive mayor of Tallahassee, favors expanding Medicaid and has embraced the idea of “Medicare for All,” which has become a rallying point for the left. Republican Ron DeSantis, a former congressman, does not and has also opposed the ACA.

FiveThirtyEight is forecasting a win for Gillum, as well as for veteran Democratic Senator Bill Nelson, who is being challenged by former governor and healthcare executive Rick Scott.

In Georgia, Democrat Stacey Abrams sees Medicaid expansion as a key piece of protecting rural hospitals, which have been closing at a rapid rate across the country. In fact, a study earlier this year found that states that embraced Medicaid expansion had fewer rural hospitals close than states that did not expand Medicaid.

Republican Brian Kemp, Georgia’s secretary of state, cites financial concerns and fear of expansion leading to a single-payer health system for his opposition to expansion. Kemp is considered to have an edge on Abrams.

Nevada’s race for the governorship between Democrat Steve Sisolak and Republican Adam Laxalt is considered a toss-up. The Senate race between incumbent Republican Dean Heller and Democrat Rep. Jacky Rosen is also neck and neck.

The ACA and Pre-existing Conditions

Republicans who voted to repeal the ACA when they voted to approve the American Health Care Act of 2017 faced attacks from Democrats and advocacy groups for their positions. The healthcare campaign Protect Our Care, launched by the bipartisan United States of Care, the group started earlier this year by former Obama administration official Andy Slavitt, released a guide to the election that details the various ways in which Republican candidates are trying to make their previous healthcare votes disappear from public view.

Some Republicans removed language from websites that boasted of their previous votes to repeal the ACA, the report said. Others are misstating their voting records.

One example: Rep. Martha McSally, fighting to become the next senator from Arizona in a race with Democrat Rep. Kyrsten Sinema, has been claiming that she has fought to protect people with pre-existing conditions. PolitiFact rated that claim as “mostly false,” noting her 2015 and 2017 votes against the ACA.

Battleground House Seats

Politico named 11 areas of the country likely to tip blue, shifting the balance of power in the House of Representatives. According to the Protect Our Care report, healthcare was a top Google search in more than 75% of congressional voting districts.

One of those areas includes the Philadelphia suburbs/South Jersey area, where Democrats are expected to pick up 3 seats; there are no GOP incumbents running, putting them at a disadvantage. In Pennsylvania, Republican Rep. Brian Fitzpatrick is in a toss-up race after a redistricting earlier this year.

In South Jersey, Rep. Tom McArthur is trying to hang onto his seat after being the only Republican congressman in the state to vote to repeal the ACA. He is being challenged by Andy Kim, who released an ad featuring his infant son’s health troubles.

In upstate New York, 6 of the state’s 9 Republican representatives are in competitive races: Elise Stefanik, Tom Reed, John Faso, Claudia Tenney, John Katko, and Chris Collins.

In other areas of the country, some competitive seats are in play because GOP lawmakers decided to retire. That includes conservative Orange County, California, where 2 of the 4 seats up for grabs are held by outgoing representatives.

State Ballot Initiatives

There are several state ballot initiatives beyond Medicaid expansion. One is in California, where a union-led effort called Proposition 8 would limit the profit of dialysis clinics in the state. Depending on which side you’re on, it is either an effort to improve patient care or it could jeopardize it by threatening the financial viability of clinics. Dialysis providers DaVita and Fresenius have spent $111 million trying to defeat the measure.

A Massachusetts ballot measure would cap the number of patients that nurses are assigned in a hospital. The idea is to improve patient care, but hospitals are opposed to the measure, saying it would cost too much. If enacted, hospitals would be fined up to $25,000 per violation, per day, for noncompliance, The Boston Globe reported.