This is the second in a series of posts I’ll be doing on the elections and their aftermath here in the US. I wrote a post focused on what the elections mean for K-12 education in the US a couple of weeks ago. This one focuses on what the election means for the healthcare in the US.

When the Republican party took over all three branches of government in 2016, repeal  replace (or simply, repeal) became one of the the explicitly stated main goals of the administration and congress. By this they meant repealing the Affordable Care Act 2010 (aka Obamacare) and replacing it with something that met most of the policy objectives of the ACA, without being the ACA.

The GOP was particularly opposed to specific aspects of the ACA system; the mandate (and associated fine for not enrolling) and the protection for pre-existing conditions being the main ones. However, the most significant attempt to repeal the Affordable Care Act was voted down in the Senate with three Republican senators: Collins (ME), McCain (AZ), Murkowski (AK) voting against repeal.  Sen. John McCain (AZ) dramatically voting no, as the last vote.

While administration and the Republican leadership in Congress seemed to leave it at that, the Democrats decided to go on offense.

The ACA survives and expands

They turned the 2018 midterm elections into a referendum on the Affordable Care Act. Aware that the ACA markets and the associated expansion of availability of Medicaid to more and more citizens had turned the tide on the bills unpopularity. For the first time since its enactment in 2010, Obamacare’s favorability was over 50% in most national polls in the run up to the 2018 elections.

One of the campaign issues used by many Democratic candidates was to portray Republican opposition to the bill as support for bringing back the pre-2014 days of exclusions based on pre-existing conditions. This part of the ACA, which makes it illegal for insurers to exclude any policy buyer based on their prior health status is the most popular aspect of the ACA. Democrats hammered their opponents on this issue.

Now, with the Democrats in charge of the House, it is unlikely that any legislative attempts to gut the ACA will come up for a vote, let alone succeed. Defenders of the ACA may be able to rest for a couple of years.

What the 2018 elections did achieve, however, is further expansion of the ACA through ballot initiatives and governors’ elections. Idaho, Nebraska and Utah passed ballot initiatives for their states to accept Medicaid expansion funds from the federal government. While, Kansas and Maine elected new governors to replace incumbents who had blocked passage (Kansas) or implementation (Maine) of medicaid expansion.

If all five states end up finalizing their respective passage and implementation of medicaid expansion, this will bring the number of states that have availed themselves of the federal money and reduce uninsured levels to 38 out of 50.

What’s next?

While legislative action to repeal or weaken the ACA is unlikely over the next two years, the administration could continue to hamper the successful implementation of the system through rule changes that relax the requirement of state administrations and insurers. Whether these will succeed or not, is debatable.

A very real risk to the ACA is from a lawsuit against the bill’s consumer protections brought by 20 state attorneys general from Republican controlled states. The lawsuit is currently before the

On the other side of the isle, Democrats seem to be moving on to the next set of healthcare reforms ranging from the incremental to the radical (in how much they tinker with or completely re-shape the current healthcare financing structure in the US). There are at least eight different so-called ‘Medicare-for-all’ proposals being shopped by various Democratic legislators. See here for an early pre-elections description on what the terms mean by Dylan Scott over at Vox.