Big Health Policy Implications Loom with 2016 Election

For Health Policy, State Races Matter, Too, in 2016

As Democrat Hillary Clinton and Republican Donald Trump vie for the U.S. presidency, a host of state-level political races affecting health policy will also play out across the country.

Most significant in individual states is whether to expand Medicaid. As of September 2016, 19 states had still not expanded the federal entitlement to people with incomes 138 percent above the federal poverty level.

“On a statewide level, the obvious issue of main concern to hospitalists will be Medicaid expansion,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “I think as state-level elections unfold, the makeup of state legislatures will impact whether expansion happens or not.”

If Clinton is elected, states with Democratic governors are likely to expand Medicaid if they have not already done so, says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. He suspects conservative Republican governors might hold out longer.

“In the states that haven’t expanded Medicaid, the election of the governor and the legislature matters a great deal because if Clinton wins that means that we’re not going to repeal the [ACA], you’re not holding the line for the new Republican plan, it’s not going to be repealed in the next four years, and the question is, does your state deny the funds for the coverage and income it gets over a matter of principle?” says Blendon.

Dr. Lenchus says issues like scope-of-practice changes could impact policies for physicians in individual states as well, such that, in some states, discharge summaries following a hospital visit could be sent to nurse practitioners or physicians assistants instead of family physicians.

Bigger changes could also be on the horizon as a little-mentioned provision of the ACA, called Section 1332, becomes a possibility in 2017 if the law survives. It allows individual states to apply for waivers to eschew all or parts of the ACA in favor of plausible attempts to create customized state-level health reform.

In Colorado, this appears as a referendum in the upcoming election for universal healthcare, called ColoradoCare. In Hawaii, it is an expansion of its four-decade-old Hawaii Prepaid Health Care Act, based on employer-provided insurance combined with subsidies and limits on premium costs. Waivers must be approved by the U.S. Department of Health & Human Services and the U.S. Department of the Treasury.

Blendon believes a public option to private health insurance is most likely at the state level rather than at the federal government level under a Section 1332 waiver.

“I would expect that some number of states, particularly without enough plans coverage [as some companies leave the ACA marketplace], would argue that the states should offer a plan, which would be run by the state government and subsidized,” says Blendon.

–Kelly April Terrell