Healthcare is a top issue for voters heading into the midterms in less than two weeks. A recent Kaiser Family Foundation poll found that of the 1,200 adults surveyed, 71% said healthcare was "very important" to them — more so than the economy or jobs.
With Democrats typically more trusted on healthcare issues and Republicans getting nervous, President Donald Trump is expected later Thursday to take aim at drug pricing within the Medicare program.
How the midterms shake up the healthcare sector depends largely on which of three possible scenarios becomes reality. Here's a look at the implications for each scenario for Congress, after the votes are counted.
1. Democrats take control of the House and Republicans retain the Senate
Pollsters say if there is disruption to the current state of affairs, this is the most likely scenario.
Dividing power in Congress would mean gridlock likely preventing much of anything from getting done. Still, it would give Democrats veto power over some policies that could hit providers and insurers, perhaps most notably full repeal or other changes to the Affordable Care Act.
Pharmaceutical companies and potentially PBMs could be among the most impacted, given Trump's moves on drug pricing. And addressing the opioid crisis has been a key issue for lawmakers from both sides of the aisle.
Trump signed a bipartisan bill Wednesday that provides some targeted funding, grants more access to medication-assisted treatment for substance misuse disorder and takes steps aimed at curbing overprescribing.
On the provider and payer side, Height analysts called out Centene, Molina and WellCare as winners in this scenario given their footprint in the individual market. Hospital companies HCA, Tenet, Community Health and Universal Health would also benefit with ACA repeal off the table.
Height said others coming out on top in this case would include generic manufacturers like Baxter, which would benefit under passage of the CREATES act.
2. Republicans keep control both the House and the Senate
Under this status quo scenario, the GOP would likely take another swipe at the remaining provisions of the ACA after failing to repeal the law several times this year.
Even as some Republicans contend they will protect patients with pre-existing conditions, Senate Majority Leader Mitch McConnell said last week they would try repeal again if enough Republicans win Nov. 6. "If we have the votes to completely start over, we'd do it," he told Reuters.
Analysts with Height Research are skeptical Republicans would try repeal attempts again. Still, there is some risk given Republicans would have the power to do it.
That would affect Centene and Molina with significant Medicaid managed care populations. Disruption to the individual market could lead to a higher rate of uninsured people or drive some to seek cheaper alternatives like short-term plans that can deny coverage for pre-existing conditions. More members in short-term plans potentially creates unbalanced risk pools, likely leaving people with chronic conditions in the exchanges and driving up costs.
For payers, the same control in both chambers would be viewed as a positive in some aspects, analysts have said.
Managed care companies would likely see "continued flexibility of underwriting" for products like short-term plans and association health plans, according to Leerink. Just this week, the administration released guidance urging states to grant more access to association and short-term health plans.
A Republican-controlled Congress would likely keep the "focus on incremental reforms" such as expanding health savings accounts or repealing remaining ACA taxes, experts at Avalere said.
Lanhee Chen, a former policy adviser to then presidential candidate Mitt Romney, said the GOP would keep the push to transfer more power to the states in coverage. This is the "sort of arc that they would pursue going forward," Chen said.
One issue Republicans are likely to avoid is stabilization for the ACA exchanges, Chen said. "It doesn't message well" with voters and he's "not convinced that the market is there for a stabilization piece of legislation."
3. Democrats flip both chambers
A so-called blue wave could lead to an expansion of some public programs with inherent benefits for payers like Centene, which has key business in managing Medicaid member for states. The payer reported an uptick in overall membership for the third quarter this week along with a surge in revenue.
Those with the most to gain would likely be managed care companies under this scenario, Leerink analysts said.
Chen said red state governors will be under pressure to expand Medicaid, an issue on the ballot for four states next month.
"I just think that this [avoiding expansion] is going to become a more and more difficult thing for governors to do," Chen said at the recent America's Health Insurance Plans conference on Medicaid and Medicare.
"If they continue to choose not to do it, then voters may force their hands in states where there is a direct referendum process," he said.
Residents of Maine voted in favoring of expanding the program last year, but Republican Gov. Paul LePage has continued to refuse to expand Medicaid despite the state's approval of a ballot referendum. LePage's term ends in January.
If Democrats are in control, the ACA is on safe ground, and conversations would likely center on how to expand public health programs, Avalere experts said. "The discussion of reform will not be over," they said. "Look for the debate over expanded access to new or existing public health programs to heat up, as Democrats position for 2020."