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2018 U.S. Midterm Elections Outcomes Debrief

Policy makers discussion

HIMSS Chapter Advocates and state/local-focused partners enter a new advocacy season with many new opportunities to engage new and current state legislators, governors and other state officials about the value of health information and technology.

The 2018 midterm elections saw more than 6,000 state legislative seats in the running along with 36 open governorships. Before this, there were 34 states with trifectas (one party held the governorship and both houses of the state legislature). Twenty-six of 34 trifectas were Republican and eight were Democratic.

Results posted on Ballotpedia indicated the following election outcomes:

Overall, 11 total states saw a trifecta status change in some way.

  • Alaska: divided government to Republican trifecta
  • Colorado: divided government to Democratic trifecta
  • Illinois: divided government to Democratic trifecta
  • Kansas: Republican trifecta to divided government
  • Maine: divided government to Democratic trifecta
  • Michigan: Republican trifecta to divided government
  • Nevada: divided government to Democratic trifecta
  • New Hampshire: Republican trifecta to divided government
  • New Mexico: divided government to Democratic trifecta
  • New York: divided government to Democratic trifecta
  • Wisconsin: Republican trifecta to divided government

The Role of Medicaid Expansion on Election Outcomes

Healthcare was a significant issue to voters during the 2018 state midterm elections. Largely, state candidates prioritized healthcare focusing on Medicaid expansion from the Affordable Care Act (ACA). Prior to Nov. 7, 17 States had not chosen to expand their Medicaid coverage.

ACA’s Medicaid Expansion requires a state to provide Medicaid coverage for persons under the age of 65, and with incomes equal to or below 138 percent of the federal poverty level – covering 10 percent of the costs associated with the expansion.

The midterm state elections saw a number of states place healthcare directly on their ballot. For instance, voters from Idaho, Nebraska and Utah approved measures to adopt Medicaid expansion.

Here is how expansion efforts rolled out across states:

  • Utah added a stipulation to increase in their sales tax from 4.7 to 4.85 percent help finance the expansion.
  • Montana and Oregon, both of which have expanded the Medicaid program, left the decision of how to continue financing the expansions to their constituents.
  • The citizens of Oregon chose to increase assessments/taxes on health insurance premiums to create additional revenue in support of the Medicaid expansion in specific hospitals.
  • Montana voters declined to increase taxes on all tobacco products, including electronic cigarettes, to fund the expanded eligibility of Medicaid and other health programs. Without this additional funding, some services will expire in mid-2019.

Medicaid expansion is important to the health information and technology community because it expands access to coverage for millions of Americans that fall below the poverty line. HIMSS Chapter Advocates and state partners will need to keep strong situational awareness of these issues, given the opportunities it brings to expand digital health across the spectrum of care within states.

The Centers for Medicare and Medicaid (CMS) has granted states opportunities through the Medicaid 1115 waiver program, or the 90 percent enhanced federal financial participation (FFP) for Medicaid technology investment (aka 90/10 Match), to modernize state health IT systems and improve prevention, early identification, and treatment of both physical and behavioral health needs.

Expansion states also have access to new more flexible funding opportunities that can empower states and local health providers to improve response to public health crises such as the opioid epidemic and chronic diseases through surveillance and care integration across the spectrum of community providers.

Most recently, CMS has expanded opportunities of the program by allowing certain technology initiatives to be funded at 90 percent for design/development/implementation, and 75 percent for operations/maintenance (note: this is not HITECH funding which runs out in 2021, but our ongoing technology funding for systems). You can find more details in this letter from CMS to state Medicaid directors.

Key Areas That May Impact the Progression of Digital Health in the U.S.

Based on the 2018 midterm elections, HIMSS Chapter Advocates may take action to elevate the role of health information and technology by addressing the following areas:

  • State action on the opioid crisis
  • Health IT and public health IT modernization
  • Medicaid expansion
  • Expanding access to care to underserved populations
  • Telehealth
  • States CAR members should pay close attention to these updates
  • The newly elected Governor of Kansas, Laura Kelly, and Governor of Wisconsin, Tony Evers, both pledged to expand Medicaid.
  • Similarly, Janet Mills, the incoming Governor of Maine, hopes to ignite action on the long-delayed Medicaid expansion in her state.

HIMSS State Government Affairs Actions

The HIMSS State Affairs team will continue to monitor new state health IT policies and initiatives through 2019 by tracking:

  • Governors’ state-of-the-state addresses or priorities
  • State strategic plans (Medicaid, opioids, etc.)
  • Statewide health IT modernization efforts
  • HIMSS State Health IT Advocacy Days

HIMSS members, chapter advocates and leaders can find more information on state and local efforts by visiting the HIMSS Policy Center.