With the 2018 midterm election season in full swing, health care has emerged as one of the top issues for voters. The issue is playing a prominent role in many House, Senate, and gubernatorial races, and health-related measures have made it onto the ballot in several states. Democratic candidates, in particular, have made health care a central part of their campaigns and a focus of their political ads, highlighting popular provisions in the Affordable Care Act (ACA), including protections for people with pre-existing medical conditions. Republican candidates, in contrast, are talking less about health care following their failed attempt to repeal and replace the ACA last year, focusing more on taxes and immigration in their ads. Based on a review of media coverage and political advertising by candidates during the current election cycle, this election update explores select health care issues being discussed by candidates in key gubernatorial and Senate campaigns across the country as voters prepare to go to the polls in November. The tables in the Appendix highlight which of these select health care issues have been prominent or served as topics of candidate debate in each of the 71 races for Governor and Senate; a third table lists state ballot initiatives on these health care issues. The aim of this review is to assess where health care issues have been a focus of the candidates, not to assess the impact of these issues on voters.
Key Health Care Issues in Statewide Races and Ballot Measures
Medicaid Expansion and Other Program Changes
While not typically an election issue, Medicaid — particularly the Medicaid expansion created under the Affordable Care Act (ACA) — has become an important issue in a number of campaigns throughout the country. To date, 34 states including the District of Columbia have adopted the ACA’s Medicaid expansion. States may implement the expansion at any time, and while they can no longer receive 100% federal financing for three years, they remain eligible for enhanced federal financing of 93% in 2019 and 90% in 2020 and beyond.
Medicaid expansion has been more prominent in gubernatorial races than in Senate races, though it has surfaced in key Senate races in Florida and Texas. Particularly in non-expansion states, gubernatorial candidates have staked out opposing positions on whether to adopt the expansion, largely mirroring the long-standing ideological divide surrounding the ACA. In key races in Florida, Georgia, and Kansas, Democratic candidates have expressed support for Medicaid expansion as a way to increase coverage and improve access to care. Several Democratic candidates in red states where past efforts to expand Medicaid have stymied, particularly Stacey Abrams in Georgia and Laura Kelly in Kansas, tie Medicaid expansion to the future of rural health care in their states by arguing that Medicaid expansion will bolster rural hospital finances and prevent further rural hospital closures. Citing financial concerns and fears that it would be a step toward a single-payer health care system, Republican candidates in these states have opposed expanding Medicaid.
In addition, candidates in two key open gubernatorial races in states that have expanded Medicaid have softened positions on the Medicaid expansion since their states’ primaries. In Michigan, Republican candidate Bill Schuette, the current Attorney General, has long opposed the ACA in general and the Medicaid expansion in particular, vowing during the primary campaign to repeal the expansion. More recently, during the general election campaign, he has said Medicaid expansion is “the law” and “it’s not going anywhere.” Next door in Ohio, Republican candidate Mike DeWine also retreated from opposition to Medicaid expansion following his primary win, indicating that he would maintain the program if work requirements are implemented. Democratic gubernatorial candidates in both states support expansion and oppose adding work or other requirements.
Medicaid expansion has also made it onto the ballot in three states — Idaho, Nebraska, and Utah — giving voters the authority to decide whether their states will adopt the expansion. Voters in Montana will also decide whether to extend Medicaid expansion beyond 2019. Not surprisingly, Medicaid expansion has been a point of disagreement in Idaho and Nebraska, where both Democratic candidates support expansion and the Republican candidates oppose the expansion but have indicated that they will enforce the will of the people.
While expansion has dominated campaign platforms that include Medicaid, other Medicaid issues have entered the campaigns in a few states. In Iowa, the shift of the state’s Medicaid program to managed care has been controversial. Republican Governor Kim Reynolds, who is running for reelection, supports the effort, while her opponent, Democrat Fred Hubbell, does not. Implementation of Medicaid managed care has also proven contentious in Kansas.
The Affordable Care Act
Protections for people with pre-existing conditions
Among the most popular provisions in the ACA are the protections provided to people with pre-existing medical conditions. The ACA prohibits insurers from denying people coverage or charging them more because they have a health condition. The ACA also outlaws pre-existing condition exclusions as well as annual and lifetime limits on coverage, which curb insurer liability but often leave people with significant health needs with inadequate coverage. According to recent polls, a majority of the public says that it is very important to maintain these protections.
Among health care issues, the debate over pre-existing condition protections has been most in the spotlight in the 2018 midterm elections. In many races, Democrats who support these protections have made the issue the centerpiece of their campaigns. In light of the strong public support for protecting those with pre-existing medical conditions, nearly all candidates from both parties say they want to see these protections maintained. However, a number of Republican candidates have had to defend prior positions that many argue would undermine these protections, including backing repeal of the ACA or supporting current legal challenges to the ACA that, if upheld, would eliminate these protections. For example, in the tight Senate race in Missouri, Republican candidate and state Attorney General Josh Hawley has signed on to Texas v. Azar, the latest legal challenge to the ACA. In response to criticism of this position, Hawley has also said that he supports maintaining pre-existing condition protections in any ACA replacement proposal and has proposed an invisible reinsurance program as a better approach.
While candidates are discussing pre-existing condition protections in a number of races, the issue is particularly salient for Senate Democratic incumbents running for reelection in states that President Donald Trump won in 2016. Claire McCaskill, who is running against Hawley, is one such Democrat, as is Joe Manchin of West Virginia, who is running against Republican candidate and state Attorney General Patrick Morrisey, who also signed on to Texas v. Azar. In North Dakota, Democratic incumbent Heidi Heitkamp is fighting the same battle against Republican challenger Kevin Cramer, who as a congressional representative voted in 2017 to repeal and replace the Affordable Care Act and weaken its pre-existing condition protections. Other Republican candidates who voted for this bill — the American Health Care Act of 2017 — are facing attacks from their Democratic opponents and outside groups, including Martha McSally in Arizona’s Senate race. Incumbent Senator Joe Donnelly, Democratic nominee in Indiana, has strongly emphasized his support for pre-existing conditions while his Republican opponent, Mike Braun, claims support for pre-existing condition protections despite supporting legislation and lawsuits to weaken them. While this issue is more central in the Senate races, it has featured prominently in several key gubernatorial races, including Florida, Ohio, and Wisconsin.
The Individual market
While the debate over pre-existing conditions has dominated many campaigns, other issues related to the ACA and its future have also been important. Although efforts to repeal and replace the ACA failed last year, some candidates in midterm races continue to call for repeal. In Michigan, for example, Republican gubernatorial candidate Bill Schuette has expressed support for repealing and replacing the ACA. However, this position is not as common as it was in the previous two midterm elections (2010 and 2014).
Rather than trying to avoid talking about the ACA as they have in past elections, Democratic candidates are focusing on ways to improve it through proposals to stabilize and shore up the individual market. For example, the Democratic gubernatorial candidate in Michigan, Gretchen Whitmer, supports the ACA but acknowledges that premiums are too high. To address these costs, she has proposed stabilizing premiums in the individual market through a state reinsurance program, similar to those adopted in several states.
The concept of a single payer health system gained attention during the 2016 presidential campaign, with Bernie Sanders making his “Medicare-for-All” proposal a foundation of his platform. This issue, more than others, highlights the wide gulf between progressive Democratic candidates who view the proposal as a way to address affordability and access challenges and conservative Republican candidates who characterize the proposal as a step toward socialism.
While candidates in traditionally blue states, such as Kirsten Gillibrand in New York, can safely advocate for a Medicare-for-All proposal, Democratic senatorial candidates in traditionally red states, facing strong attacks from Republican opponents on the issue, have taken more nuanced positions or have stated their opposition to the idea. Democrat Beto O’Rourke in Texas, who is running against incumbent Republican Ted Cruz, has not shied away from support for universal coverage; however, he does not advocate Medicare-for-All as the only approach. Instead, he has highlighted his goal of universal health care coverage through solutions such as Medicaid expansion, ACA market stabilization, and creating a public option on the exchanges, while acknowledging that single-payer would also achieve this goal. Kyrsten Sinema, who is locked in a tight race against Martha McSally in Arizona, is similarly focusing on “realistic and pragmatic solutions” but has said that she does not support Medicare-for-All.
Democratic candidates in gubernatorial races have been more forthright with their support for a single-payer or Medicare-for-All system, even those in more conservative states. For example, Democratic candidate Andrew Gillum in Florida beat more moderate rivals in the state primary and is running on Medicaid expansion and movement to a single-payer health care system. While he would not be in a position to vote on federal health care laws such as Bernie Sanders’ “Medicare for All” bill that he supports, Gillum has made progressive health care positions central to his campaign. Gavin Newsom in California and Jared Polis in Colorado have also voiced support for Medicare-for-All.
At the same time, Republican candidates have intensified attacks on Democrats’ support for Medicare-for-All as a step toward socialism. Gillum’s Republican rival, Ron DeSantis, has not yet unveiled a detailed health care platform but has consistently opposed the ACA and Medicaid expansion. He has attacked Gillum’s positions and health care platform as “socialist.”
Abortion and Women’s Reproductive Health
With the confirmation in October of Supreme Court Justice Brett Kavanaugh, abortion is once again in the political spotlight. In the near future, the Supreme Court could hear a case that could challenge existing federal protections of abortion rights under Roe v. Wade, as well as other subsequent Supreme Court rulings. Sixteen states already have laws in place that would prohibit abortions in the state if Roe were to be overturned, and other states have passed laws expressing their intent to limit access to abortion to the maximum extent possible. In contrast, nine states have laws protecting women’s access to abortion in the possible absence of Roe.
During their general elections, Senate and gubernatorial candidates have treated abortion as a divisive issue and varied regarding whether or not to highlight it in their races. In the Tennessee Senate race, for example, Republican candidate and incumbent Marsha Blackburn has a strong pro-life history, including as a leader of past efforts to investigate and stop all public payments to Planned Parenthood for family planning services. Despite that history and the fact that Blackburn’s opponent, Democrat Phil Bredesen, has expressed his pro-choice views and support for continued funding of Planned Parenthood, abortion has not come to the forefront in the race. In Iowa, the Republican nominee is current Governor Kim Reynolds, who in May 2018 signed the “heartbeat” bill — one of the country’s most restrictive abortion prohibitions — into law. She has maintained solid support for this bill, which is currently being stayed during litigation, while her Democratic opponent Fred Hubbell has expressed his opposition to the bill and highlighted his support for Planned Parenthood funding. On the campaign trail, some candidates have addressed state and federal payments to Planned Parenthood. For example, incumbent Republican Senator Roger Wicker of Mississippi has been outspoken in his support of state efforts to exclude Planned Parenthood from receiving Medicaid reimbursement for family planning services, whereas his opponent, Democrat David Baria, has voiced support for continuing funding to Planned Parenthood.
Ballot measures in three states — Alabama, Oregon, and West Virginia — also address abortion. The West Virginia measure, if approved, would amend the state constitution to stipulate that there is no state protection of abortion rights, laying the groundwork for state prohibition of abortion if the Supreme Court overturns Roe v. Wade. In Alabama, the ballot measure goes further, adding language to “recognize and support the sanctity of unborn life and the rights of unborn children, including the right to life.” If enacted, this language could have wide-ranging implications, including making abortion illegal in the state. It could also affect state policies on access to contraception and in vitro fertilization services. In Oregon, a state with generally broad protections for abortion, the ballot measure would prohibit public funding for abortions, jeopardizing state funding for abortions under Medicaid, except when medically necessary or when required by federal law (when pregnancy is the result of rape or incest or poses a threat to the pregnant woman’s life).
Health care is shaping up to be a central issue in this year’s midterm elections. In a number of key gubernatorial and Senate races, protections for people with pre-existing conditions, Medicaid expansion, and even Medicare-for-all are important campaign issues. Although not included in the discussion here, these issues are resonating in House races across the country as well. This year, with increased public support for the ACA, the traditional battle lines over these issues have been upended. Democrats, who had been defensive on the ACA in past elections, are now embracing aspects of the law, even if they do not reference the law by name. While many Republican candidates still oppose the ACA, the simple message of repealing the ACA risks alienating moderates and even some Republican voters who have benefited from the ACA’s coverage expansions and insurance market changes. Instead, these candidates are now pledging support for maintaining popular pre-existing condition protections, even as they criticize other aspects of the law.
The outcome of the election could prove pivotal to the future of the ACA and the Medicaid expansion. Despite the popularity of some provisions of the law, Republicans in Congress have indicated that if they retain control, they will try once again to repeal and replace the ACA. If, however, Democrats gain control of the House, it is likely the ACA will remain in place. At the same time, voters in Idaho, Nebraska, and Utah will have a direct say in whether their states adopt the Medicaid expansion. In several other non-expansion states, the outcome of gubernatorial races could move their states closer to expanding Medicaid. Although health care has been an important topic in the midterm campaigns, voters’ response to a broad range of issues will determine the outcome of elections for Governor and Congress and will ultimately shape the next round of health care policy.