The 2020 election outcomes will be one of the largest influencers on state healthcare policy priorities in coming years. These elections hold long-term healthcare implications for many state policymakers, with a presidential election, Congressional elections deciding 35 US Senate seats and 435 US House seats, 11 gubernatorial elections, and elections in 86 of 99 state legislative chambers in November.

State responses to mitigate the long-term health outcomes resulting from the COVID-19 pandemic will likely make healthcare a top priority for both Republicans and Democrats after the elections. Issues relating to access to care, rising out-of-pocket (OOP) costs, and other patient affordability challenges could fall to state policymakers if political gridlock persists at the federal level. Dependent on the federal dynamics, states may decide to address issues of healthcare costs, coverage, and access in 2021 and beyond, including:

• Prescription Drug Importation: On September 24, the Food & Drug Administration released the Importation of Prescription Drugs final rule. The rule finalizes the administration’s plan to allow for state importation of certain prescription drugs from Canada through newly created Section 804 importation programs. Currently, 6 states (CO, FL, ME, NM, NH, and VT) have passed laws that seek federal approval to create importation programs and to date, CO, FL, and VT have submitted proposals to Health & Human Services. While federal elections may impact how these programs operate, both the Trump and Biden campaigns have been supportive of prescription drug importation in the past. Following the elections in November, state policymakers may be likely to increase legislative initiatives to create plans for prescription drug importation.
• Coverage Expansion and Reform: The COVID-19 pandemic has highlighted gaps in healthcare coverage. Election outcomes at the federal and state levels could impact the availability of current and new coverage options. A recently released Congressional Budget Office report on health insurance coverage in 2019 found that 6 million Americans do not have access to employer-sponsored insurance but are above the income threshold to qualify for Affordable Care Act (ACA) exchange-subsidized premiums. According to the report, 3.2 million Americans with incomes below the federal poverty level live in states that have not expanded Medicaid and therefore do not have access to this coverage. Election outcomes—coupled with the impact of the COVID-19 pandemic on the long-term sustainability of quality and equitable healthcare across many states—may lead state and federal policymakers to introduce coverage expansion proposals or reforms in the individual market and Medicaid.
• Patient Assistance Programs: Election outcomes will influence how policymakers choose to address patient OOP and prescription drug costs. This could include either increasing or restricting the use of manufacturer patient assistance programs such as copay cards or free drug foundations. Many uninsured or underinsured individuals and those with exchange coverage rely on manufacturer patient assistance to pay for prescription medications. Additionally, enrollment shifts due to the COVID-19 pandemic and the potential movement of covered lives from the exchanges if the Supreme Court invalidates some or all of the ACA may increase the need for these programs. Dependent on the political leanings of both Congress and statehouses following the elections, some state policymakers could look to set parameters on state-regulated insurers and patient assistance programs, such as requiring insurers to count manufacturer copay cards or coupons towards patient OOP costs or limiting copay card use when a generic is available.

Elections are not the only key influencers for state legislative and regulatory priorities. The pending US Senate confirmation vote on the US Supreme Court judicial nomination will have important implications for state policymakers, including in California v. Texas, concerning the constitutionality of the individual mandate and possibly the entire ACA, and Rutledge v. Pharmaceutical Care Management Association (PCMA), concerning the role of states in regulating pharmacy benefit managers’ drug reimbursement. These pending Supreme Court cases, with decisions expected over the next year, will affect how many states establish long-term healthcare priorities.

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