MH: In an analysis leading up to the midterms, you said that while voters rank healthcare as a top concern, pundits overstate its impact when people actually vote.
Altman: Healthcare absolutely was before the election, and now we know after the election, overall the top issue. That does not mean that it was the top factor driving people’s vote. That was mostly (President Donald) Trump, but also things like how people felt about the candidates themselves, or issues in the state, occasionally that was Medicaid, or a variety of other factors.
Everybody sees these polls, which show the top issue, and they think the election is about that issue. Elections are almost never about the top issue.
For Republicans, before the election or in the exit polls, it was not even remotely the top issue; immigration was. Healthcare was an important way to motivate Democrats, somewhat independents, but never Republicans.
MH: The elections were a big night for Medicaid expansion. What impact do you think the ballot initiatives will have more broadly?
Altman: It continues momentum for Medicaid expansion with the referendums passing in the three states and maybe, even more importantly, the election of the governors in Kansas and Maine who will move forward.
At the same time, it’s not a Medicaid wave because of the defeat of Andrew Gillum in Florida and Stacey Abrams (who at deadline was trailing) in Georgia. Florida in particular has outsize importance politically as a state coveted by both parties in every election.
There’s more than Medicaid expansion involved in this. As these states expand, and as governors invested in Medicaid win, you have more and more red states and purple states with a stake in Medicaid. So it changes the politics of Medicaid completely and makes it harder, if not impossible, for a future Congress to return to big cuts in federal Medicaid spending in the form of a block grant, or per capita cap, or some other form.
It’s not just a matter of looking at it in coverage terms and how many people get coverage. You also have to look at how it does or doesn’t affect the national politics of Medicaid.
MH: What do some of the gubernatorial switches mean for Medicaid work requirements and waivers?
Altman: Work requirements are a … huge fighting issue between the left and the right on principle and do affect significant numbers of people. Work requirements will be affected by another fallout from the election—aggressive and relentless oversight by Democrats in the House. And that will be in every area, but it will certainly be in healthcare, and a lot of it will focus on Affordable Care Act waivers and Medicaid waivers.
That will include work requirements and how they are working out, how many people are losing coverage, and whether they are consistent with the intentions of the statute, and the rules governing 1115 waivers.
Both Democratic and Republican administrations have used waivers to achieve all kinds of policy objectives that they believe in, moving far beyond the strict legal limits of the waiver authority.
There’s a debate about work requirements and premiums and all kinds of Medicaid issues, but it isn’t a bad thing if we have a fresh discussion of what should and shouldn’t be doable through administrative authority, which is supposed to be limited to research and demonstration purposes and never has been. So the oversight authority will be an important unfolding story.
MH: What do you think we can expect regarding Medicare?
Altman: There are a couple things going on. One is the Democratic control of the House, and the second is the departure of (retiring Speaker of the House) Paul Ryan, who was the champion of premium support. The combination of those two things means that big Medicare restructuring, especially premium support, is dead for now.
Whether it ever really could have gone anywhere is another question. But the presidential election begins any second and Republicans will be loath to put anything on the table that will hand Democrats Medicare as an issue.
We can have a great debate about how much healthcare is a voting issue, but we know that Medicare is. That leads me to believe that nothing big will happen on Medicare. There may be some Medicare budget savers, and often they stitch together a variety of payment cuts, or to be technical, reductions in the rate of increases in payments. But none of them big enough to create a huge political problem.
There will be an effort in the House—a big effort—to bring Democrats together around some kind of coherent health policy agenda. But that will not work with the presidential candidates. The presidential candidates will all be out advancing the platforms that they think appeal to the slices of the Democratic base that give them the best chance to win the nomination.
So they will be kind of somewhat all over the place, some pushing “Medicare for all,” some as an option, some building on the ACA, some may emphasize other things like drug prices. Medicare will be in the middle of all that.