2018 Midterm Election: Impacts on Public Health Priorities

November 08, 2018|1:30 p.m.| ASTHO Staff

With the Democrats in the majority in the U.S. House of Representatives and the Republicans maintaining control of the U.S. Senate for the next two years, ASTHO anticipates these changes will have an impact on public health, including the federal budget, oversight, ACA, and the potential for gridlock in Washington, D.C.

A divided Congress will continue to grapple with budgetary issues especially in light of the ballooning federal debt and deficit. Under current law, sequestration returns next year with a slated $55 billion cut to non-defense discretionary funding. Adjusting the budget caps to provide additional resources will be one of the most significant issues Congress will need to address in the new year. If a budget deal is not reached by late-winter, gridlock will ensue, resulting in a high potential for a government shutdown in October.

ACA repeal and replace will no longer be on the docket for the next two years. House Democrats may try to bolster the program with minor changes to the insurance marketplaces, but these types of modifications will need to be approved by a 60 vote majority in the Senate. One of the main public health provisions in the ACA, the Prevention and Public Health Fund, remains vulnerable, as both Democrats and Republicans might attempt to use it to pay for other priorities.

We anticipate Congress will continue to address the opioid epidemic. However, the focus may now shift from legislating to implementation of the new SUPPORT for Patients and Communities (P.L. 115-271) law, as well as oversight of how states, territories, and local health departments are utilizing the new federal resources dedicated to the opioid crisis. Other public health issues the 116th Congress will most likely address are maternal morbidity and mortality, suicide prevention, infectious disease, and prescription drug pricing.

However, before the new session begins in January, Congress must finish their work during the upcoming lame duck session on appropriations bills, including those funding FDA, WIC, EPA, and the Agency for Toxic Substances and Disease Registry. These agencies and programs are currently operating under a continuing resolution through Dec. 7. Additionally, Congress must approve the Pandemic and All Hazards Preparedness Act (PAHPA) prior to the end of the year. Otherwise they will have to start the whole process all over again.

In sum, while it is very difficult to anticipate what will happen in Washington D.C., one thing is very clear: with the 2020 presidential election on the horizon and a divided Congress, state and territorial public health will have to work diligently to ensure that Congress and the Administration prioritize protecting and promoting the health of all Americans.

State Legislatures and Governors

In addition to a shifting federal landscape, there were significant state and territorial changes, in both legislatures and gubernatorial elections. More information and further details about state and territorial legislative and gubernatorial changes can be found at the National Conference of State Legislatures and the National Governors Association.

Ballot Measures

During the midterm elections, votes were also cast on a number of state ballot measures related to public health issues, including Medicaid expansion, tobacco pricing, marijuana use, healthcare services, and sugar sweetened beverages. Below is a brief summary of the ballot measure results.

In Idaho, Nebraska, and Utah, voters elected to expand Medicaid. In Montana, where votes are still being counted, a proposal to fund Medicaid expansion through tobacco price increases faces rejection. Idaho’s Proposition 2, approved by 61 percent of voters, expands Medicaid to those whose income is at or below 133 percent of the federal poverty level (FPL) and who are not eligible for other state insurance coverage (effectively expanding healthcare coverage for anyone at or below 138% FPL).

In Nebraska, 53 percent of voters approved Initiative 427 to expand Medicaid to those at or below 138 percent FPL. Neither of the measures in Idaho or Nebraska establish funding mechanisms for Medicaid expansion. Utah’s Proposition 3 was approved by 54 percent of voters to expand Medicaid to those at or below 138 percent of FPL and fund the expansion with a 0.15 percent increase to the state’s sales tax. According to the Kaiser Family Foundation, there are fourteen states that have not expanded Medicaid. However, with gubernatorial changes in Wisconsin and Kansas, there is now a chance of Medicaid expansion in those states.

Montana’s Initiative 185 would increase the price per pack of cigarettes by $2 as well as increase the tobacco wholesale rate to fund the state’s expanded Medicaid services beyond next year’s scheduled expiration of current funding. Reported ballots the day after the election showed 46 percent support for the proposal.

Another tobacco price increase was on the ballot in South Dakota. The measure would increase the per pack price of cigarettes by $1 and the tobacco wholesale rate by 20 percent, with the additional revenue used to fund tuition and financial support for students in state technical institutes. Voters ended up rejecting the proposal by a 55-45 percent margin.

Proposals related to marijuana and hemp were on the ballot in five states. Utah voters approved a medical marijuana initiative (Proposition 2) by a 53-47 percent margin. The proposal establishes oversight for the production and distribution of medical marijuana, prohibits the medical marijuana from being smoked, and sets the qualifying conditions for medical marijuana. However, implementation of the initiative is in question since the Utah governor has vowed to call a special legislative session for consideration of a substitute bill. A unique feature of the proposed substitute bill is the creation of a state-run medical marijuana pharmacy (see page 7 of this overview).

In Missouri, voters had a choice between three separate medical marijuana ballot measures. In the end, they rejected two of the proposals (Amendment 3, 69-31%, and Proposition C, 56-44%) and approved the third, Amendment 2, with 66 percent of the vote. Amendment 2 gives the Missouri Department of Health and Senior Services oversight of the state’s medical marijuana program, allows qualifying patients to grow marijuana at home, and allocates sale proceeds to a Veterans’ Health and Care Fund.

Michigan joins nine other states, the District of Columbia, and the Commonwealth of the Northern Mariana Islands in allowing adults to use marijuana for non-medical purposes. By the end of election night, 55 percent of Michigan voters approved Proposal 18-1 to permit the use, growing, and possession of marijuana by anyone ages 21 years and older. The measure also directs Michigan’s Department of Licensing and Regulatory Affairs to oversee the commercial production and retail sale of marijuana.

Meanwhile, North Dakota voters handily defeated a marijuana decriminalization measure. By a 59-41% margin, voters rejected the proposal to permit the use of marijuana by adults 21 years and older and expunge criminal convictions related to marijuana. Similar to Vermont and the District of Columbia’s marijuana laws, the North Dakota measure would not have allowed the commercial production and retail sale of marijuana.

In Colorado, 61 percent of voters approved a constitutional amendment to change the definition of industrial hemp to match the federal definition or as defined by state statute. Support for this proposal seems to be tied to provisions in the federal farm bill that would remove industrial hemp from the definition of marijuana and potentially open the door for hemp-derived cannabidiol production.

Ballot measures involving healthcare services and staffing were defeated in two states. Voters in Maine rejected a measure for universal home healthcare by 63-37%. The proposal would have established a program to provide in-home healthcare and social services to older adults with physical and mental disabilities and set out a funding mechanism (see page 4 of the state’s voter guide). In Massachusetts, a proposal to set nurse-to-patient assignment limits was rejected by 70 percent of voters. The limits would have been based on the various degrees of needed care and would not be imposed during public health emergencies (see page 4 of this voter guide).

Finally, in Oregon and Washington, voters considered similar measures that would impact the ability of local jurisdictions to increase the pricing of sugar sweetened beverages. While framed as a prohibition of local taxes on groceries, the proposals would also preempt local jurisdictions from regulating the price of sodas and other sugar sweetened beverages—a strategy some localities have undertaken as a way to reduce obesity and promote healthy eating. It is also telling that significant financial contributions were made by national beverage companies and associations to supporters of the proposals. While Oregon voters rejected their ballot measure with 57 percent voting against it, voters in Washington approved their initiative by a 55-45% margin.

As we move toward the new year, ASTHO will continue to monitor the results and implementation of new ballot measures, as well as the public health impact of shifting priorities in state, territorial, and federal legislative activities.

Tell us what you think icon that links to blog evaluation form