It’s been a surprising electoral campaign in many respects, but from a health policy standpoint, what isn’t happening is perhaps as surprising as what is happening. For the first election cycle since passage, the anti-ACA dog is barely barking. And while it is far too soon to take anything for granted, Secretary Clinton has opened up a substantial lead in the polls at a point in the campaign when polls begin to matter.

If Clinton does prevail in November, will it create an opening in Washington to build on the ACA and correct some its shortcomings? And will the opposition finally learn to love the ACA? Probably not (very probably not). First of all, there are very limited points of agreement between the two parties with respect to the ACA. Aside from agreement on repealing the “Cadillac tax” and bipartisan bills to reduce cost-sharing for people with chronic conditions, the two parties want to move health policy in very different directions, at least with respect to coverage. But even these limited points of agreement face headwinds in the form of disagreements about how to offset their cost to the treasury.

Secondly, bear in mind the GOP platform and the House Republican health care blueprint call for major cuts to Medicare and Medicaid that would reduce coverage and increase costs for millions of beneficiaries. If these 50-year-old programs are still in the crosshairs, why would the ACA to be any different? Finally, consider that the basic forces driving political polarization have not abated. So, while the “hot war” may subside a bit (fewer repeal votes), we can expect a health policy “Cold War” to continue until the basic political dynamics change or until one party or the other receives a new electoral mandate.

 

States to the Rescue?

While political gridlock continue to stymie progress on health policy in Washington, the same is not necessarily true in the states. It seems every week more evidence piles up on the benefits states reap from closing the Medicaid coverage gap. Last week was no exception. Recent studies highlight how closing the gap reduces uncompensated care, provides economic and fiscal benefits to states and improves the health and economic well-being of enrollees. At the same time, new evidence shows closing the gap does not lead to a spike in emergency room utilization, a concern often raised by opponents. 

And the political winds may also be shifting in favor of closing the gap, as both voters and local government officials lose patience with state inaction. With President Obama exiting the political arena, a Clinton win could set the stage for progress among the 19 holdouts that have not yet expanded coverage.

But state progress will not necessarily be limited to closing the gap. Other issues are also likely to get a fair share of attention. One big issue gaining ground in states is addressing surprise out-of-network bills. With the rise of narrow network plans both on and off ACA marketplaces, more and more people are finding themselves paying unexpected medical bills even when they try to stay within their health plan network. California’s legislation addressing surprise out-of-network billing has a good chance of passing this year. But the issue has legs not only in blue states but in red states, too. Texas is considering steps to protect consumers from surprise bills. Progress in the two biggest states – with wildly disparate political environments – could prompt similar action across the country.

Two other state initiatives to watch are ballot measures in California and Colorado. The California proposal would reduce the amount some state programs have to pay for prescription drugs, while the more far-reaching Colorado measure would create a single-payer system in that state. Both measures face a tough road. Opponents are heavily outspending proponents, and the Colorado measure recently suffered a setback when a fiscal analysis found the revenue sources for the proposal were not adequate to cover the costs. But as long as lawmakers in Washington remain stuck in the political mud, we can expect states to keep pushing the boundaries in searching for solutions to our nation’s pressing health care problems.