November 6, 2018

The Election Day stakes for health care, mapped

Daily Briefing

    By Ashley Fuoco Antonelli, Contributing Editor, and Jackie Kimmell, Senior Analyst

    On Tuesday, voters across the country will cast their ballots in this year's midterm elections—and if there's been one theme throughout this year's election cycle, it's that the stakes are high for health care.

    The midterms' outcomes could mean the difference between having health coverage or being uninsured for millions of U.S. residents—but coverage isn't the only thing at stake. Let's take a closer look.

    What's at stake in the states?

    Medicaid expansion

    At the state level, the largest health care issue is Medicaid expansion.

    An Avalere Health analysis released this week found that nearly 2.5 million U.S. residents could gain access to Medicaid coverage via possible expansions if Democratic gubernatorial candidates are elected in Florida, Georgia, Kansas, South Dakota, Maine, and Wisconsin—and Medicaid expansion has been front and center in those races.

    In three other states—Idaho, Nebraska, and Utah—voters will decide whether to expand Medicaid to an additional 325,000 residents through ballot initiatives. In Montana, voters will decide whether to extend the state's current Medicaid expansion and whether to raise state taxes on tobacco products to fund it. And in Oregon, voters will decide whether to uphold taxes on health insurance and hospital revenue to fund its Medicaid expansion.

    Health care ballot issues you may not have heard of  

    But Medicaid expansion isn't the only health care issue at stake.

    In California, voters under California Proposition 4 will decide whether the state should issue $1.5 billion in bonds to children's hospitals for construction, equipment, expansion, and renovation. California Proposition 8 is arguably the more controversial health care ballot: Voters will decide whether dialysis clinics must provide refunds to patients and payers if revenue exceeds 115% of the costs of providing care to patients and implementing care improvements. Finally, voters will also vote on Proposition 11, which would allow ambulance providers to require workers to remain on-call during breaks, and require employers to provide EMTs additional training and some paid mental health services.

    Elsewhere, Massachusetts voters under Question 1 will decide whether the state should establish limits on how many hospital patients can be assigned to registered nurses—a topic that has divided the industry. The state currently has similar restrictions for ICUs, but has not expanded the mandate to other parts of the hospital.

    In Nevada, voters under Question 4 will decide whether to require the state's Legislature to exempt durable medical equipment, oxygen delivery equipment, and mobility enhancing equipment prescribed by licensed health care providers from the state's sales and use tax.

    In Maine, voters under Question 1 will determine whether to create a program called the Universal Home Care Program, which would provide long-term home health services to elderly and disabled regardless of their income. The program would be funded with a 3.8% tax on state citizens making more than $128,000 per year.

    In addition, there are several other health-related measures at the state level including:

    • Massachusetts' Question 3, which will call on voters to decide whether that they want to keep a law prohibiting discrimination based on gender identity in public places, including doctor's offices, hospitals and other medical care sites;
    • New Mexico's Bond Question A, which would authorize the sale and issuance of $10.77 million in bonds for senior citizen facilities; and
    • Oklahoma's State Question 793, which would allow opticians and optometrists to practice in retail establishments.

    Public health-related measures

    In Washington and Oregon, two similar grocery tax-related measures are up for a vote. Oregon's Measure 103 would prohibit both state and local governments from enacting taxes on groceries and Washington's Initiative 1634 would prohibit local governments from enacting taxes on groceries.

    While the measures have been framed in ads as supportive to budget-conscious moms and small farmers, opponents say the messages are misleading– as their major financial backers are large American beverage companies like Coca-Cola and PepsiCo. These companies, opponents claim, are supporting the measures to stop a growing movement on taxing soda and other sugary drinks. As Jim Krieger, a professor of medicine and health services at the University of Washington said to the New York Times, "No one is even talking about taxing food, this is simply the soda industry trying to protect its profits at the expense of public health and local democracy."

    In other public health-related initiatives, South Dakota voters will decide on Initiated Measure 25, which would increase taxes on tobacco by $1 per pack of 20 cigarettes and increase the tax on wholesale tobacco products from 35 to 55%. Ohio voters will weigh in on Issue 1, which would make drug possession and use liable for no punishment greater than a misdemeanor and require the state to redirect saved funds from the reduction of inmates to drug rehabilitation programs. The measure's proponents say it would help address the opioid crisis in the state. Finally, Nevada, under Question 2, could become the 10th state to provide sales tax exemptions for feminine hygiene products. 

    Marijuana-related measures

    Voters in several states also will consider ballot initiatives focused on marijuana, both for medical and recreational use. For instance, Missouri voters:

    • Under Amendment 2 will decide whether to amend the state's constitution to legalize marijuana for medical use and implement a tax on marijuana sales that is used to fund health care services for veterans;
    • Under Amendment 3 will decide whether to amend the state's constitution to legalize marijuana for medical use and implement a tax on marijuana sales that is used to fund a Biomedical Research and Drug Development Institute; and
    • Under Proposition C will decide on whether to legalize marijuana for medical use and implement a tax on marijuana sales that is used to fund veterans' services, drug treatment, education, and law enforcement.

    Similar questions on are the ballots in Oklahoma and Utah. In North Dakota, voters under Measure 3 will decide whether to legalize the recreational use of marijuana for individuals ages 21 and older and to establish a process to automatically expunge individuals' convictions for possessing a controlled substance that has been legalized. Michigan voters under Proposal 1 will decide whether to legalize the recreational use and possession of marijuana for individuals ages 21 and older, as well as whether to tax marijuana sales.

    What's at stake at the federal level?

    At the federal level, midterm election results could mean the difference between reducing or expanding coverage for millions of U.S. residents.

    Senate Majority Leader Mitch McConnell (R-Ky.) last month said congressional Republicans might again try to repeal the Affordable Care Act (ACA) if they gain larger majorities in the House and Senate in Tuesday's elections. Though Republicans have failed to advance ACA repeal proposals in the past, they could prove successful if they gain large enough majorities in both chambers.

    On the Democratic side, candidates have been touting so-called "Medicare-for-All" proposals to expand coverage to U.S. residents. Although a Medicare-for-All proposal likely wouldn't be implemented under President Trump, gaining seats in Congress could set Democrats up to coalesce around and advance such a proposal in the future.

    An eye on the polls

    The Daily Briefing will be watching the election results stream in Tuesday, so be sure to check in with us on Wednesday, when we'll bring you the latest updates on how these issues were decided and analysis on what these developments will mean for providers.

    No matter who wins: Here's your health policy outlook for 2019

    Bradford Koles, Jr., Executive Director

    With a new administration firmly in place, Congress has taken steps to repeal and replace the Affordable Care Act—but the effort remains incomplete. While the political winds continue to shift, executives must set course amid a new wave of health reforms.

    Join me on Thursday, November 8 to hear the 2018 State of the Union, Advisory Board's objective analysis of the most important trends impacting provider strategy today.

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