The votes have been counted, the results are (mostly) in: What’s next for health care?

Ever since the legislative battle over the passage of the Affordable Care Act, health care has dominated the political landscape in the United States. First, the bruising fight to enact the Affordable Care Act. It was followed by the equally bruising battle over its implementation, which has lingered on.

Early on, it brought with it dramatic electoral losses by Democrats at both the federal and state levels, which handed Republicans control of both chambers of Congress as well as many governorships and state legislatures.

Yet after two years of full-on assaults on the health law under unified Republican control in Washington, D.C., health care was once more a dominant issue for most voters. This time around, health care appears to have helped Democrats with significant increases in the House of Representatives as well as many state races. As Republicans expand their majority in the Senate and with President Donald Trump in the White House, how will the midterm election results change anything going forward?

The big winner: Medicaid (and Medicare)

In a night with mixed results, Medicaid came out a winner in a number of ways. For one, without control of the House of Representatives, efforts to undo the expansion under the Affordable Care Act, capping spending on the program by block granting it, or implementing a statutory provision for work requirements are off the table.

At the state level, changes are also profound. In three red states, Utah, Nebraska and Idaho, voters told their legislators to expand the program, potentially adding insurance coverage to more than 300,000. Moreover, Democratic gubernatorial wins in Wisconsin, Kansas and Maine could move those states toward expansion.

Yet, Medicaid could have done even better. A ballot initiative to fund the state’s Medicaid expansion via tobacco taxes failed in Montana under heavy assault by tobacco companies. If the legislature does not provide continued funding, Montana may be the first state to undo the Medicaid expansion. Republican wins in Alaska could also undo the expansion there.

Moreover, initiatives in Nebraska and Idaho did not include a funding mechanism, which may delay expansion there. Perhaps most crucially, millions more could have moved closer to insurance coverage with Democratic wins in Georgia and Florida.

The elections also brought mixed prospects for the future of work requirements for Medicaid beneficiaries. Newly elected Democratic governors in states like Wisconsin, Kansas and Michigan may seek to weaken or undo them, while newly elected Republican governors in Ohio and Florida may seek to strengthen and expand them.

Finally, loss of the House of Representatives also means that Republicans will be stymied in their attempts to curtail and privatize Medicare, the insurance program for America’s seniors.

Close second: Medical marijuana

Despite continued federal opposition, the country seems to move decisively towards the legalization of marijuana. For one, while a measure was defeated in North Dakota, Michigan followed its neighbor to the north and became the 10th U.S. state to allow recreational marijuana use. Two other states, Missouri and Utah, moved to become the 31st and 32nd states to allow medical marijuana. Giving the growing evidence that marijuana may help counter the devastating opioid epidemic, these developments may prove quite positive from a health care perspective.

Too early to tell: The Affordable Care Act

The Affordable Care Act is likely safe, for two years anyway, after Democrats gained control of the House of Representatives Nov. 6, 2018. txking/
As with Medicaid, the Democratic takeover of the House brings some relief for the Affordable Care Act. The effects on the Medicaid expansion have been discussed above, but more generally, Democrats in Congress can now hold up any major statutory effort to undo or undermine the Affordable Care Act.

Yet despite Democratic gains across the nations, three major factors that could substantively affect the Affordable Care Act remain largely out of their control.