Seismic healthcare changes unlikely regardless of election winners
I love this time of year. I am a political junky through and through!
The presidential and congressional elections are tomorrow in what is one of the closest races of modern times. While Trump appeared to be surging in the last week or so there is some evidence that the race again is tightening. The unknowns are: (1) how much has Harris’ closing message impacted undecided voters and (2) has historic undercounting of GOP support in the polls in many swing states continued or been solved.
Here is where things stand right now.
President
Right now, odds show Trump ahead in most betting markets but Harris has closed the gap a little. The Real Clear Politics (RCP) betting averages is at about 58% for Trump, down from about 60% a few days ago. The popular vote is back to a tie in the RCP average, with the last seven polls showing 4 ties, Harris ahead in two, and Trump ahead in one.
Trump is ahead about 0.9 percentage points in the seven key battlegrounds. In the Rust Belt swing states, Harris is up 0.6 in Michigan and 0.4 in Wisconsin, with polls in each state in the past few days showing both candidates on top. Trump is up 0.3 in Pennsylvania in the polling average.
As for the Deep South and Sun Belt swing states, Trump generally looks in better shape, where he has been consistently ahead (except for one recent poll in a few states). The only state that looks a little vulnerable for him is Nevada as he did not win the state in either 2016 or 2020.
Even if Harris wins Nevada, she has to sweep the three Rust Belt states to win the presidency. If Trump wins the four Sun Belt and southern swing states, he has to win just one of Pennsylvania, Wisconsin, or Michigan. If Trump wins the Sun Belt and southern swing states and no Rust Belt states, he could still win if he converts either New Hampshire or Virginia as two examples.
Thus, in the electoral college, Trump still looks favored going into tomorrow – but anything is possible.
Senate
The Nebraska races look better for the GOP going into tomorrow. The Texas and Florida races look relatively OK for the GOP. West Virginia and Montana will flip to the GOP, giving them at least 51 seats to control the Senate. Depending on the outcomes of races in Wisconsin, Michigan, Pennsylvania, Arizona, Ohio, and Nevada, the GOP number could increase by one, two or more. If I had to pick the most vulnerable Democratic incumbent outside of the almost-certain Montana flip, it would be Ohio’s Sherrod Brown. The current polling at the top of the ticket is very much in favor of the GOP.
House
House control remains highly competitive, with betting odds and pollsters split on the outcome. Some say there is a better shot at Democratic control, while others say Republicans have a narrow advantage. While coattails could matter, control likely comes down to a few races where local issues may decide. Regardless, either party will have a very narrow working majority.
Likely no seismic changes in healthcare
Notwithstanding the vast differences between the parties on healthcare, I would not expect seismic changes in healthcare policy.
A GOP White House will almost assuredly mean a rockier road for the Exchanges and Medicaid coverage. There still could be bipartisan efforts to reform Medicare Advantage, pharmacy benefits managers, and more.
But with the Senate almost sure to be Republican, there will be a bit of a moderating force on radical change no matter who controls the more philosophy-driven House and White House. The Senate assuredly will be more conservative on the GOP side after the election, but there are two true moderates (Alaska’s Lisa Murkowski and Maine’s Susan Collins) as well as a few other more pragmatic conservatives. These folks as well as the filibuster likely would stop radical GOP proposals, such as repeal of major elements of the Affordable Care Act (ACA) and major structural changes to Medicaid (such as block grants and removing the entitlement nature of the program).
If both houses are GOP-controlled, the extension of the enhanced premium subsidies in the Exchanges may be dead. A Democratic House will fight for it and that could mean the Senate agrees to a temporary extension in an overall compromise bill foe budget purposes. There is still an outside chance that enhanced subsidies could be part of a broader tax and other spending compromise regardless of who controls the House and White House.
On the flip side, the Senate filibuster and its makeup would also serve to stop radical Democratic or progressive proposals, such as Medicare for All. This is so because of some moderate Democrats in the upper chamber as well.
Possible exception
There is one possible exception to my theory above on radical change. If the House retains GOP control, Trump regains the White House, and the Senate GOP picks up well more than 52 senators, a budget reconciliation measure could include major ACA and Medicaid structural changes. This could mean enough Senate GOP votes to move such a measure. In essence, Collins and Murkowski hold less sway in this situation. Such a budget reconciliation measure could happen at any time, including to extend tax cuts that expire.
But passing a full repeal or substantial changes to the ACA or restructuring of Medicaid through budget reconciliation is not without complications and there is good reason to think that many GOP members of the Senate and House may have second thoughts given previous election fallout. For example, the Senate GOP is defending an expected 20 of 33 seats up in 2026.
Possible savings from Medicaid
If the GOP were in charge of both chambers, it still could seek reductions in Medicaid to help pay for tax cuts. It seems to have taken Social Security and Medicare off the table. In lieu of radical Medicaid restructuring, it might reduce Medicaid expansion population funding from 90% and reduce the current 50% floor in Medicaid matching funds. Of course a Democratic house would not support such moves.
But chances for overall reform would be dim
At the same time, prospects for real healthcare reform will dim. A complete control by the GOP would stymie attempts to drive affordable universal access, which I view as critical to healthcare reform (along with price reform and a pivot to care management from utilization management). A split Washington of any type would likely mean at least two more years of constant bickering on healthcare and at best tinkering on the fringes of healthcare reform. This is because whoever controls the House will hail from either of the extremes. The White House likely would also govern from the extremes regardless of the outcome. Moderate forces would stop extremist changes, but the extremes would stymie real reform.
Unfortunately as well, there is likely little chance that lawmakers take seriously the crisis we have in Social Security, Medicare, and Medicaid. They simply will not sit down and craft sound and long-lasting solutions to stabilize these critical social safety nets.
#election2024 #harris #trump #healthcare #healthcarereform
— Marc S. Ryan
