Prediction: It will be another ‘health care election’

The 2018 midterms were a “health care election.” Mobilized by the Republican Congress’ attempts to repeal the Affordable Care Act, midterm voters turned out in the highest percentage since 1914 and sent Democrats to control the House of Representatives.

The 2017 election in Virginia was a health care election, too. More than 70 percent of Virginia voters said that health care was a top issue when they went to the ballot box, and the legislators they sent to Richmond finally expanded Medicaid to more than 300,000 Virginians.

2016, the first time Republicans got the chance to repeal the ACA, was a health care election. So was 2014, the year after the debut of HealthCare.gov. 2012 was a health care election, since it was the first time President Barack Obama went before the voters after signing the Affordable Care Act into law, and it went a bit differently than the 2010 election — also a health care election — held right after the ACA passed.

So today, with about a week to go, I am willing to make a bold and shocking prediction: 2019 will probably be a health care election.

I make this Nostradmus-like call based on a few data points — candidates in Virginia have spent thousands this year on health care focused political ads, and voters list health care higher than the economy as a “very important” issue. There’s also the small matter of, oh I don’t know, the entire history of the past decade.

Virginia’s last health care election in 2017 led to a sea change in Virginia politics and health policy. Today, more than 325,000 Virginians are enrolled in coverage through expanded Medicaid. In many ways, the health care headline in this election is whether voters will protect those gains in coverage. But there is a wealth of proactive and interesting, if deeply wonky, health care proposals that the new Virginia legislature could consider in 2020.

First of all, Virginia could finally take control of its health insurance market by turning its health insurance marketplace into a fully state-run marketplace. Today, when Virginians shop for a health insurance plan on HealthCare.gov, they’re using a site fully run and operated by the federal government. But under a state-run Marketplace, Virginia could put more resources into outreach to connect with uninsured people. The state could offer more customer support to help people navigate their health insurance options. They could even give Virginians more time for Open Enrollment, when they can shop around for new plans.

Second, Virginia could make health plans cheaper by expanding the subsidies on the Marketplace. Today, an individual earning up to about $50,000 can get some kind of financial support to lower their premiums for health plans on the Marketplace. A family of four earning up to around $100,000 can as well. In fact, most people shopping on HealthCare.gov will find some sort of financial assistance, but there are some who still aren’t eligible for subsidies. (The calculation changes based on different factors, so everyone should check HealthCare.gov before deciding whether they can afford a health plan.)

States like California have expanded subsidies — both offering more financial assistance, and offering it to people with higher incomes. As a result, families in those states could see enormous savings this year. Early estimates from health care analyst Charles Gaba show a 50-year-old married couple in California with an adult child could save more than $12,000 a year.

Third, Virginia could make the insurance market more stable, so insurance companies would offer plans at lower premiums. The state could do this through a reinsurance program — a program originally established in the Affordable Care Act, sabotaged at the federal level by Sen. Marco Rubio, but reestablished at the state level elsewhere. States that have created their own reinsurance program have seen health insurance premiums drop by an average of 20 percent in the first year.

Finally, Virginia could take a bold move and open up its Medicaid program to even more people. Specifically, by creating a buy-in option to Medicaid, the state could at once open up a new health insurance option to people who have trouble finding affordable coverage in the private market. And with the “buy-in” part of the plan, this proposal could bring in additional revenue to help balance costs across the state.

Next week we’ll resolve yet another health care election, but this year’s has the chance to be something different. For years we’ve been caught in these massive, existential battles over whether tens of millions of Americans would get coverage, or tens of millions would lose it. We debated fundamental things — like whether people should still be denied health insurance because they’ve had a pre-existing condition, or whether we should allow annual or lifetime limits on health coverage. Those things are still at stake at the federal level; the Trump Administration at this moment is trying to repeal the entire ACA through the courts which would send Virginia’s (and the entire United States’) health care system into a spiral.

But this year’s health care election gives Virginia the chance to start a new decade with new ideas on health reform and leave the old battles, and the old health care elections, behind.