The results of the November 6 election will help shape key areas of policy heading into 2019 and the next session of Congress. Avalere offers the following observations as Election Day approaches:

Republicans have a choice to make on the Affordable Care Act (ACA) if they maintain control of Congress

“If Republicans hang on to both houses of Congress, leadership will face a choice on how, or if, to address the Affordable Care Act in the next session.” — Elizabeth Carpenter, senior vice president at Avalere.

If Republicans maintain control, they could steer clear of healthcare and the ACA or renew efforts at repeal and replace. More likely, Avalere experts note that a Republican-controlled Congress may focus on incremental reforms (repealing remaining ACA taxes, expanding health savings accounts, etc.) while the administration continues to pursue change via its regulatory authority. Importantly, the 2018 election season has demonstrated that preserving protections for patients with pre-existing conditions is top of mind for voters across the country.

Democrats are likely to drive a discussion over an expanded role for public health programs

“If Democrats take control, watch for debate on how best to expand the role of public health programs, especially Medicare, headed into the 2020 presidential race.” — Chris Sloan, director at Avalere

Democrats on the campaign trail and in Congress are lining up behind any number of proposals to introduce a public option, allow individuals to buy into Medicare, or move to a Medicare-for-All system. While victory by Democrats in one or both houses of Congress likely puts the ACA on safe ground from a legislative perspective according to Avalere experts, the discussion of reform will not be over. Look for the debate over expanded access to new or existing public health programs to heat up, as Democrats position for 2020.

While the administration will continue to grant flexibility to states looking to reform Medicaid, the expansion landscape will be shaped by state elections

“State elections have the potential to reduce the number of uninsured in several states.” — Tiernan Meyer, director at Avalere

Medicaid expansion had the largest impact on the number of people with insurance of any reform implemented as part of the ACA. Yet, 17 states have not expanded Medicaid. Medicaid expansion is on the ballot in 3 states (ID, NE, and UT), while Democratic gubernatorial candidates in states like Florida and Georgia are running on the promise of expanding the program. Legislatures will have a role to play in whether a new governor can enact change, but the issue could appear on agendas in several non-expansion states based on election outcomes.

The administration’s focus on drug pricing will continue regardless of the election outcome

“Steps to implement the administration’s drug pricing blueprint are likely to be unaffected by the outcome of the 2018 mid-terms.” — Matt Brow, president at Avalere

Experts at Avalere say that stakeholders should continue to watch for additional regulatory reforms to Part D, changes to the anti-kickback safe harbor that permits manufacturer drug rebates, and demonstration projects focused on prescription drugs, regardless of the 2018 election results. Should Democrats take the House and/or Senate, the President could get onboard with legislation focused on drug prices, if Congress were able to get consensus. Meanwhile, state drug pricing activity will march forward, building on this year’s busy legislative session that witnessed 21 states considering legislation and 5 states enacting laws.

The viability of calls for fiscal discipline may depend on election outcomes

“A focus on fiscal discipline is likely to return to Washington heading into the next session of Congress.” — Elizabeth Carpenter.

With the federal deficit at its highest level since 2012, calls for fiscal discipline in Washington are once again returning. However, the politics associated with deficit reduction are complicated. Meaningful spending reform may require bipartisan support as well as cuts to programs like Medicare, neither of which are popular heading into a presidential election. Nevertheless, if Republicans lose control, Avalere experts note that the focus on spending could intensify. Long term, a split government in which both parties share control (and therefore accountability) may be the most opportune time for fiscal reform.

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