The 2018 midterm election was a big one, with candidates running on starkly different visions for the country, major ballot initiatives, and the highest voter turnout in a midterm election in more than 50 years. Health care was a key issue in many candidate’s races and in key ballot initiatives, so how might the election affect state and federal health care policy over the next two years?

First, an important caveat: elections matter—quite a lot—but they’re only one piece of a healthy democracy. True political and economic democracy requires democratic participation, governance, accountability, ownership, and adherence to human rights in all spheres of life. When it comes to health care, political and economic democracy requires us to replace private, profit-driven health care, which is structurally incapable of guaranteeing health care to all, with a system that is specifically designed to meet human health needs and provides a universal, unequivocal public guarantee of access to quality care. A change that big can never be won through mere voting and political representation: it requires a movement. Thus even as we engage in elections, we must also tell our health care stories, expose private profiteering, hold elected officials accountable, and recognize ourselves—not legislators—as the real agents of change.

That said, here’s what happened in last week’s elections.

Medicaid:

• Federal protection: With Democrats taking control of the U.S. House, Congress’s threats to the Affordable Care Act (Obamacare) and attack on Medicaid are now squarely off the table. That said, attacks will continue in the courts and at the state level in Republican-controlled states with ongoing encouragement from the Trump administration. The administration can act without Congress by loosening federal requirements on how states regulate private insurance plans and by all allowing states to push people off of Medicaid by imposing work requirements, paperwork requirements, asset disqualifications, and other punitive measures. (After being granted federal approval, Arkansas has pushed thousands of people off of Medicaid in recent months.)
• Big wins for red-state expansion, but continued threats: Voters passed ballot initiatives to expand Medicaid in Idaho, Utah and Nebraska, and Maine voters elected Democrat Janet Mills as governor, who will enact the Medicaid expansion that Maine voters passed last year. Hundreds of thousands of uninsured poor people in these states will gain access to health care in the coming months, an enormous win. The newly elected governors of Kansas and Wisconsin are also expected to work with their legislatures to expand Medicaid. If they succeed, access to health care would be extended to another 300,000 people. On the other hand, it is important to note that 14 states, mostly in the South, are still resisting Medicaid expansion, and last week Montana voters defeated a ballot initiative that would have continued the State’s Medicaid expansion beyond this year. (Opposition to the initiative misleadingly framed Medicaid expansion as a tax hike.) The state legislature could still pass legislation to continue the expansion, but it’s uncertain how that will pan out. In the coming year, we should expect Republicans in many states to continue to create new “work requirements” that serve to push people out Medicaid as well as out of public housing and SNAP (food stamps).

Universal health care:

• The struggle over Medicare for All: In Congressional races, the election was neither a slam-dunk for proponents of Medicare for All nor centrist Democrats who favor tweaking the existing insurance system. Both progressives and centrists won and lost elections. A big struggle over the future of healthcare is shaping up, and though the struggle is driven by extra-governmental actors ranging from grassroots human rights movements to corporate lobbying groups, the fight will be largely mediated through the Democratic Party. It will begin in earnest in February when National Nurses United and other proponents of universal, publicly financed health care will hold nationwide actions in an effort to force House Democrats to move HR 676 (the Expanded & Improved Medicare For All Act) through the House Ways and Means Committee and the House Energy and Commerce Committee to a vote on the House floor. These committees could be key venues in which key details of implementing universal, publicly financed healthcare (financing, benefits, and other matters) could begin to be worked out. But although the bill has already been co-sponsored by a majority of the Democratic caucus, Nancy Pelosi and other party leaders who oppose Medicare for All are trying to maintain the upper hand by keeping the bill from moving forward. All of this is a prelude to the real fight, which will play out in the first half of 2020 during the Democratic primaries. And as this shapes up, enormously powerful healthcare industries are preparing. The insurance, hospital, and drug industries and their allies have formed at least three corporate lobbying groups to scare voters and elected officials out of shifting from private to public insurance and limiting their profits.
• Exciting potential in New York and California: Centrist Democrats Andrew Cuomo and Gavin Newsom won the governorships in New York and California. Cuomo has resisted residents’ demands for universal, publicly finance health care, while Newsom has voiced support but has stopped short of endorsing proposals. Both states now have Democratic majorities in both houses of their state legislature, and New York’s legislature is now decidedly more progressive. Thanks to the hard work of people organizing in both states as part of the Campaign for New York Health and Healthy California, New York’s universal health care bill (the New York Health Act) has passed the Assembly multiple years in a row and came just one vote away from passing the Senate last year, and California’s SB 562 passed the Senate, though the Democratic leadership of the Assembly has refused to let the bill come to a vote. The pressure is now on Cuomo, Newsom, and Senators and Assemblymembers to act. There is real potential, but political power-holders are cautious by nature and do not take bold action unless their hand is forced. They are likely to be particularly hesitant the next two years while national healthcare politics remain in flux.
• Setbacks in Florida and Maryland: Though Cuomo and Newsom won their elections, progressive gubernatorial candidates Andrew Gillum and Ben Jealous running on a universal healthcare platform appear to have lost in Florida and Georgia. (As of this writing, the Florida election remains too close to call, and is being recounted, but Gillum is behind.) The takeaway here is that there is no single takeaway. Voters are multi-dimensional people with multiple needs and desires, and with rare exceptions, no single issue is likely to swing a majority of voters in one direction or another.

Reproductive care:

• On the positive side, Democratic control of the House means Congress won’t defund Planned Parenthood, and there are more women in Congress who support reproductive rights than ever before. Oregon voters also handily defeated an initiative that would have banned public funding from covering abortions. On the other hand, West Virginia and Alabama passed initiatives that, if the Supreme Court strikes down Roe v. Wade, would make it easy for their state legislatures to completely ban abortions.

Healthcare corporations win and patients and healthcare workers lose in ballot initiatives coast to coast:

• Universal home care: Maine voters voted down a ballot measure that would have provided free, in-home, long-term care to seniors and created more jobs for home care workers. Had the law passed, it would have been the first universal long-term care program in the country. The initiative, backed by advocacy group Maine AllCare, was defeated soundly, 63 to 37. The initiative was defeated by the chamber of commerce and the home care, hospital, banking, and real estate industries, whose messaging misleadingly turned people’s attention away from the critical shortage of long-term care by framing the initiative as a tax hike that would hurt small businesses and the economy.
• Nurse-to-patient ratios: The hospital industry defeated a Massachusetts initiative that would have required hospitals to maintain better nurse-to-patient ratios. The opposition message focused on a claim that taxes would go up if the initiative passed.
• Limitless profits for clinic profits: The dialysis clinic industry spent a record $111 million to successfully defeat a California initiative backed by SEIU that would have capped clinics’ profits at 15% above the cost of delivering care and required them to pay excess revenue back to patients. Right now the dialysis industry reaps enormous profits, often charging patients 300-400% of what it costs them to deliver care. The opposition used scare tactics in its messaging, warning that the initiative would lead to substandard care, cause clinics to close, and preventing people from being able to get care.
• Workers’ rights for ambulance drivers: The ambulance industry won an initiative in California that allows them to require their drivers to remain on call during their lunch breaks. Their winning argument sidestepped a debate on the fundamental rights of their employees by framing this as a common-sense proposal to make sure that public safety personnel are available to the people who need them.

Is Congressional legislation possible?

It’s unclear what action the divided Congress might take on health care in the next two years, but three areas of action are possible: drug prices, opioids, and ACA subsidies.

• Drug prices: The Democratic House could hold hearings on drug prices, forcing drug company executives to testify on price markups. Trump, too, has been making noise about addressing drug prices, which opens the possibility Democrats, Trump, and a few Republican senators could work together to pass some sort of bipartisan legislation. Any legislation would likely tinker with regulations at the margins, such as by allowing Medicare to negotiate prices with drug companies, pinning Medicare’s drug prices to European prices, or changing regulations to make cheap generic drugs more available.
• Opioids: Although Congress just passed a big opioid bill in October, observers agree that the legislation offered only partial solutions to the ongoing addiciton crisis. Further bipartisan legislation is possible.
• ACA subsidies: Though unlikely, it is not impossible that Democrats, Trump, and a few Republican senators could work together to increase ACA subsidies (extending them to more people, increasing the amount of subsidies, or both).

Profiteers are happy

• Health care stocks soared the morning after the election as companies, whose profits have boomed under the Affordable Care Act, expect limited regulation and lots more profits the next two years.