In November, several states will hold elections: LA and MS’s governors and legislatures, the KY governor, VA legislature, and NJ general assembly.

Democratic and Republican lawmakers increasingly have divergent platforms on insurance coverage policy and Medicaid expansion (including new waivers or amendments). Overall, the elections could result in significant policy changes within states if offices are flipped and could lead to increased differences between states if majorities are maintained. The gubernatorial elections are especially significant, as each state’s election outcomes creates either a divided government or Republican “trifecta” in which 1 party controls the governor’s office and both houses of the legislature.

Kentucky

Considered the most competitive gubernatorial race in 2019, incumbent Governor Matt Bevin (R) will face KY Attorney General Andy Beshear (D) on November 5.

The outcome of the gubernatorial race is likely to have a significant impact on healthcare policy in the state. KY expanded Medicaid under former Governor Steve Beshear (D), the father of current candidate Attorney General Beshear. However, Bevin’s administration has sought to implement work requirements in the program. While the state’s 1115 waiver was originally approved in January 2018, the approval was vacated in summer 2018 following a court order and reapproved in November 2018. Legislative challenges remain, however, and the state has been blocked from implementing the work requirements. While Bevin issued an executive order stating that he would end the Medicaid expansion if work requirements are not implemented, Attorney General Beshear has expressed significant support for the expansion, and will likely seek to maintain the expansion if elected.

Louisiana

Elections in 2019 will determine the governor’s office and both chambers of the legislature. Currently, both chambers of the LA legislature are held by Republicans, while the governor’s office is held by incumbent John Bel Edwards (D). Governor Edwards (D) will face Republican businessman Eddie Rispone in a runoff election on November 16 that is currently rated as a toss-up.

LA expanded Medicaid in 2016, and the program’s design, funding, and operation have been central topics of discussion for both gubernatorial and legislative candidates. Edwards has held out the Medicaid expansion as a top accomplishment for his administration, citing a study published in August that found the expansion has increased access to healthcare services and provider participation in Medicaid, and could reduce the rate of hospital closures.

Mississippi

The governor’s office and both chambers of the legislature are holding elections in 2019. The state is currently a Republican trifecta, with Republicans holding the majority in the legislature and the governor’s office.

The current governor, Phil Bryant (R), is term limited and ineligible to run again. Therefore, the November 5 election will feature current Lieutenant Governor Tate Reeves (R) versus current MS Attorney General Jim Hood (D). While MS remains a majority Republican state with a Republican supermajority in the House of Representatives, the race has been fairly competitive.

MS has not expanded Medicaid under the ACA, although in 2018 the state submitted a 1115 waiver that requested to provide up to 24 months of transitional Medicaid coverage, intended to address concerns around the eligibility “cliff” that beneficiaries would otherwise face if their incomes rose above eligibility levels, but were still too low to qualify for exchange subsidies. Reeves has stated that, if elected governor, he would not seek to expand the program, citing financial concerns for the state. However, Hood supports Medicaid expansion, specifically mentioning a proposed expansion program offered by the Mississippi Hospital Association, “Mississippi Cares.”

Virginia

The majority in the VA legislature is currently held by Republicans in both chambers, albeit by fairly slim margins. With a number of competitive races across the state, a Democratic majority in either chamber is possible, which could lead to new healthcare coverage policy priorities.

If Democrats gain a majority in the legislature, their priorities would be to bolster the Medicaid expansion program and key provisions of the ACA (e.g., protections for individuals with pre-existing conditions, maintaining qualified health plan standards on the individual exchange). While several drug pricing-related measures were introduced in 2019, none were enacted; activity on this topic is likely to continue regardless of the outcome of the elections.

VA expanded Medicaid in 2019, although the state has submitted a waiver amendment to impose work requirements on the expansion program. While that waiver has not yet been approved, Governor Ralph Northam’s (D) administration has stated that it will consider halting the implementation of work requirements if CMS does not provide funding for job training and work-related educational subsidies. Notably, CMS has previously indicated that federal funds will not be provided for work-related training programs. In May 2019, the VA Joint Legislative Audit and Review Commission announced its upcoming report on the impact of VA’s 1115 waiver, which will examine the state’s readiness for and the potential impact of work requirement implementation.

Conclusion

With increased flexibility from the federal government for the design and operation of healthcare markets and Medicaid program administration, state elections are increasingly impactful for healthcare policy. Especially as Republican and Democratic platforms continue to diverge on key healthcare issues, the outcomes of these elections will likely significantly shape the policy landscape in the states and potentially create further variation between states on similar issues.

Find out the top 2020 healthcare trends to watch.