THE PROGNOSIS

Voters and candidates of both parties repeatedly made it clear that health care was a pressing issue leading up to tomorrow's midterm elections.

To be sure, there was a 2018 twist: Republicans who once ran on wanting to eliminate President Barack Obama’s landmark health-care law now repeatedly vow to protect one of its most popular elements. And Democrats were emboldened by the controversial law’s resurgent popularity to distinguish themselves in tight races nationwide. 

As we’ve extensively covered in The Health 202 and in The Washington Post, the outcomes of those critical races are bound to have a major impact on numerous health-care issues, depending on whether Republicans maintain control of both chambers of Congress or whether Democrats recapture the House majority. State-level races and ballot measures could also set the stage for changes in health-care policy.

Here are four of the health-care issues at stake in Tuesday’s election:

The Affordable Care Act

Voters needed only to turn on their televisions or radios, or to watch one of President Trump’s rallies, to see both Democrats and Republicans are vowing to preserve protections for people with preexisting conditions.

At first, Republicans were seemingly responding to Democratic attacks on the issue.

But in campaign's final weeks, many Republicans appeared to reverse their stances on multiple votes to repeal and replace Obamacare. “After years of owning the health-care issue in the aftermath of the [ACA’s] nearly immediate unpopularity, Republicans largely ceded [the issue] to Democrats after [the GOP's] failed attempt to repeal the law last year,” my colleague Colby Itkowitz reported. “How to handle preexisting conditions was a major flash point in the debate last year. The bills voted on did not eliminate protections for preexisting conditions, but they did weaken them considerably by giving power to the states to waive certain requirements for insures — a demand from the GOP’s most conservative members.”

Views began to shift. As my colleague Elise Viebeck wrote, “... faced with the fact that the protections are wildly popular among voters ... some Republicans have copied Trump’s approach, insisting that they will support what they once opposed with no acknowledgment of their about-face.”

One of the many examples of the dueling rhetoric is in Missouri, where Democratic Sen. Claire McCaskill has berated her opponent, Republican Senate candidate Josh Hawley, for being among the attorneys general who have brought a lawsuit against the ACA.

“You don’t go to court and get rid of important protections when there is no backup, when people will be in a free fall,” McCaskill said in a debate last month. Hawley responded that “we should repeal and replace” the ACA, saying there are alternative ways to protect preexisting conditions. “What we see from the Democrats is a full-throated defense of Obamacare,” Hawley said. He added: “Will McCaskill support any plan that isn’t Obamacare?”

The answer to that question remains to be seen.

Senate Majority Leader Mitch McConnell (R-Ky.) signaled the GOP’s desire to try again to repeal and replace Obamacare in an interview with Reuters. On the House side, Minority Leader Nancy Pelosi (D-Calif.) and her deputies told the New York Times that if Democrats are in the House majority, they plan to  improve the ACA rather than concentrate on other proposals such as a single-payer system.

And here's another view of how important health care has been nationwide. My Post colleague Andrew Van Dam mapped out Google searches that show an obvious pattern: "In almost every county in almost every month for the past year, health care topped the charts. Medicare and Medicaid were perennially popular, as was mental health," he writes. 

Medicaid

The fate of Medicaid expansion could be cast in many ways on Tuesday. There are 17 states that have yet to expand the program under the ACA. But four ballot initiatives and several governor’s races could change that.

In Maine, an open gubernatorial race could end an ongoing standoff on Medicaid expansion. Voters there overwhelmingly agreed to expand the program to many low-income people, but the measure has yet to be implemented because of foot-dragging by Republican Gov. Paul LePage. But as I wrote in The Health 202, the candidates who could succeed LePage appear more open to expanding Medicaid. Democratic candidate Janet Mills said she would implement the expansion on “Day 1,” while Republican  Shawn Moody said he would also do so as long as there is adequate funding.

The fate of expansion could also be tied to a handful of other governor’s races, in states like Florida, Wisconsin, Kansas and Georgia if Democratic candidates who signaled support for expansion succeed in replacing Republican governors who oppose it.

In Georgia, for example, Democrat Stacey Abrams has run in part on her support for Medicaid expansion. Meanwhile, Republican Brian Kemp said at a recent debate that “expanding a broken government program is no answer to solving a problem.” 

Meanwhile, voters in Idaho, Utah and Nebraska will choose whether to expand Medicaid through a ballot initiative. And in Montana, where Medicaid expansion was adopted in 2015, voters will decide whether to extend the program's expansion, which is set to expire in 2019.

Abortion rights

Several issues are poised to play out in the states, including rights to abortion access, which our colleagues Tracy Jan and David Weigel report has “motivated Democrats this election cycle more than at any time in the past decade.”

A September poll from Pew found that 61 percent of Democrats say the issue is “very important” to their vote compared with 44 percent of Republicans. That’s up 23 points for Democrats since 2008, while for Republicans the numbers remained constant.

The issue may pull more weight with voters following the ascension of Brett M. Kavanaugh to the Supreme Court, as abortion rights supporters fear the high court’s conservative shift may lead to an overturning of the landmark 1973 Roe v. Wade decision.

In Michigan, for example, “where Democrats have taken the lead in statewide races, the party’s nominee for governor, Gretchen Whitmer, has released a plan to protect abortion rights regardless of future Supreme Court rulings,” Tracy and David write. “Michigan has yet to repeal a 1931 state law banning most abortions despite the Roe v. Wade decision.”

Voters will also get to vote directly on the issue at the ballot. Three states are considering measures that could restrict or limit access to abortion in West Virginia, Oregon and Alabama. In West Virginia and Oregon, voters will decide whether to block funding for abortions by preventing state taxpayer money from covering abortions for Medicaid beneficiaries. In West Virginia and Alabama, voters will choose whether to change their state constitutions to declare that abortion rights unprotected. And Alabama’s initiative also will determine whether a fetus has “personhood” protections at conception.

Marijuana

The number of states with legal medical marijuana has doubled in the past decade, as my colleague Kate Rabinowitz points out, and the legalization of recreational marijuana has grown from two states in 2012 to nine states and the District of Columbia. That map could expand on Tuesday in four states. In Michigan and North Dakota, there are ballot initiatives looking to legalize marijuana for adult use. In Missouri, there are three initiatives to legalize marijuana for medical use, and voters in Utah will also decide on medical marijuana.

Tamar Todd, director of the Office of Legal Affairs at the Drug Policy Alliance, told me that the possibility of having marijuana initiatives succeed in conservative states “represents how mainstream marijuana law reform is, how bipartisan it is.”

AHH, OOF and OUCH

AHH: In the final Washington Post-ABC News poll ahead of Tuesday’s election, Democrats have a lead among voters who say health care is one of the single-most important issues in the election.

The survey found Democrats have a 39-point lead among voters who say it’s one of their top issues. The poll found Americans trust Democrats to better handle the issue of health care; the party has 16-point edge, leading Republicans 50 to 34 percent, as my colleagues Dan Balz and Scott Clement report.

More broadly, the survey found 17 percent of voters say health care is among the single most important issues ahead of the election, tying with the desire to reduce the country’s divisions, Dan and Scott report. “When looking more broadly at issues voters say are at least ‘very important,’ health care and the economy top the list at 78 percent and 76 percent, respectively,” they write.

OOF: Republicans are continuing to beat the drum of protections for individuals with preexisting conditions in rallies and on the final set of Sunday talk shows before the election.

Sen. Thom Tillis (R-N.C.), who himself sponsored a bill that he said would provide these protections in August (more on that bill here, and here, and here), accused Democrats of spreading a “false narrative."

"It’s a false narrative for Democrats to come in and say if you elect Republicans we’re going to take that away. We’re doing everything we can, including myself… to make sure we protect preexisting conditions," Tillis said in an interview on “Fox News Sunday.”

During a nearly 80-minute rally in Macon, Ga. on Sunday, Trump  mostly kept his focus on “broad topics like jobs, health care and education,” as Politico’s Eleanor Mueller reports.

Democrats, he said, want to “take away and destroy your health care, because that’s what’s going to happen.”

However, as my colleague Elise writes, claims from Tillis, the president and many Republicans that they have protected Americans with preexisting medical conditions is a “false claim that flies in the face of the reality of the past eight years.”

Elise continues: “The Trump administration is part of a lawsuit to invalidate the [ACA's] core protection for people with preexisting conditions such as cancer, diabetes or even a pregnancy… Many House Republicans have voted more than 70 times to scrap or undermine the 2010 law, which for the first time forced insurers to provide coverage to people who already had medical problems.”

OUCH: The Food and Drug Administration greenlighted a powerful opioid, despite the express concern of some of its advisers who warned the drug would be abused and lead to more overdose deaths.

“The opioid is five to 10 times more potent than pharmaceutical fentanyl,” my Post colleague Lenny Bernstein reports. “A tiny pill that is just three millimeters in diameter, it is likely to worsen the nation’s drug crisis, according to critics and the head of the FDA’s advisory committee on painkillers.”

Lenny reported the FDA advisory committee recommended on a 10-to-3 vote approval of the 30-microgram pill form of sufentanil, a potent painkiller often used after surgery.

FDA Commissioner Scott Gottlieb defended the agency’s decision, but said he would “seek more authority for the agency to consider whether there are too many similar drugs on the market, which might allow the agency to turn down future applications for new opioid approvals,” Lenny writes.

“We need to address the question that I believe underlies the criticism raised in advance of this approval,” Gottlieb wrote. “To what extent should we evaluate each opioid solely on its own merits, and to what extent should we also consider . . . the epidemic of opioid misuse and abuse that’s gripping our nation?”

HEALTH ON THE HILL

— So how exactly did Republicans “drive themselves into this particular box canyon” on preexisting condition protections? My colleague Paul Kane has a must-read column on how the party’s leaders caved to conservatives last year, including language in the bill to repeal and replace the ACA that weakened its “provision forbidding insurers from denying coverage because of preexisting medical conditions such as cancer, asthma or diabetes … and thereby handed Democrats their most lethal political weapon against Republicans.”

— The Democratic message in suburban districts has been all about health care, too. The question for swing voters is whether they “go with their wallets — the months of positive economic news of job and wage growth — or concerns about their health care,” my Post colleague Mike DeBonis writes.

Pelosi acknowledged the critical nature of the issue. “It’s dominant because it’s dominant in the well-being of people’s lives,” she told Mike in an interview. “It’s also dominant because we made it so.”

Here are some examples of how the pitch is playing out in districts across the country:

  • It’s all about the ads. “Late TV spending for the DCCC and the House Majority PAC, the biggest Democratic groups focused on House races, are overwhelmingly promoting messages targeting Republican health-care policy and last year’s GOP tax bill, which Democrats are arguing will prompt cuts to Social Security and Medicare,” Mike writes.
  • In the Chicago area, Democrats are going after Rep. Peter J. Roskam (R-Ill.) with an ad featuring a child in a hospital bed, warning people could go “without lifesaving treatment because it’s been denied” by insurance. “That’s what Peter J. Roskam voted for.”
  • In New York’s 19th district, Democratic ads have been targeting Rep. John Faso, “highlighting video of him promising to protect health coverage for people with preexisting conditions.” “John Faso broke his promise,” a DCCC ad says. “It’s time for him to go.”
TRUMP TEMPERATURE

— Former President Obama chimed in about health care over the weekend. At a rally for Indiana’s Democratic Sen. Joe Donnelly, the former president “criticized Republicans for passing a tax bill that benefited the wealthy, and for trying to end protections for preexisting conditions provided” his health care law, the Associated Press's Brian Slodysko and Sara Burnett report.

Obama jabbed directly Trump and Republicans on issues, saying if Republicans “want to stand up and defend the fact that they tried to take away your health care, they should do so” rather than “pretend they didn’t do it," as our Post colleagues Felicia Sonmez and Anne Gearan report.

And in Macon, Ga., Trump criticized his predecessor as well,  saying that Obama "did not tell the truth" when he said Americans "can keep your doctor, you can keep your plan" under Obamacare.

AGENCY ALERT

— A Senate report from Democrats on the Senate Finance Committee concluded oversight issues on the state and federal level led to “fatal heat strokes and chaotic evacuations at nursing homes” following last year’s devastating hurricanes, the New York Times’s Sheri Fink reports.

"Too many of them are not equipped to handle matters of basic safety in disasters,” Sen. Ron Wyden (D-Ore.), the top Democrat on the panel told Sheri.

The report, which followed after a number of nursing homes in North Carolina and Florida flooded, lost power or required additional evacuation help, found there was “inadequate regulation and oversight, ineffective planning and communications protocols, and questionable decision-making by facility administrators.”

“Officials with the Centers for Medicare and Medicaid Services, a federal agency that was a subject of the inquiry, have said they would clarify expectations for how nursing homes must maintain safe temperatures in emergencies,” Sheri writes. “Officials added in an interview this week that they were actively seeking lessons from recent disasters. But they defended the agency’s new preparedness requirements for health care providers, which did not come under enforcement until just after last year’s hurricane season.”

STATE SCAN

— The most expensive ballot measure campaign this year was in California, asking voters to decide whether kidney dialysis center profits should be capped to 15 percent above the cost of patient-care services -- with the excess revenue rebated to insurance companies.

Both sides around Proposition 8 have spent more than $120 million. But Kaiser Health News’s Harriet Rowan reports it’s not entirely clear what would come from a success for this ballot initiative.

“Both sides are making bold statements. But even the Legislative Analyst’s Office, nonpartisan officials who advise the state Legislature, said Prop 8 could result in a ‘net positive impact in the low tens of millions of dollars to net negative impact in the tens of millions of dollars,’” Harriet writes. “In other words: No one knows.”

“Dialysis companies argue that the low reimbursement rate from Medicare — which covers about 90 percent of patients — is the reason they are forced to charge more for the 10 percent who are covered by private insurance,” Harriet reports. “Those private insurance payments allow them to remain profitable. SEIU argues that high rates for private insurance contributes to higher overall health care costs and points out that the dialysis companies have a higher profit margin than hospitals in the state.”

— And here are a few more good reads from The Post and beyond: 

Fact Checker
We rounded up 47 fact-checks of Democrats, Republicans and outrageous campaign ads.
Salvador Rizzo
There's a growing effort to make sure that illness doesn't prevent people from casting ballots.
NBC News
All the different ways health care is playing in the 2018 midterms.
Vox
Politics
Tight races across the country are setting the stage for an uncertain — but dramatic — conclusion.
Matt Viser and Philip Rucker
Politics
Contests that the party had hoped to put away remain toss-ups, even as Democrats run strongly in states where they now serve as chief executives.
Tim Craig
If they hold the House, they may try "repeal" — but again stumble on "replace."
Politico
Across the country, some candidates are shouting for gun restrictions they would once have advocated in whispers, if at all.
The New York Times
INDUSTRY RX
Delaying the tax pads insurers' profits.
Axios
One of the most popular electronic health records software systems used by hospitals, Epic Systems, can delete records or require cumbersome workarounds when clocks are set back for an hour, prompt…
Kaiser Health News
Health
Maureen Pacheco underwent a lumbar fusion procedure in 2016 and woke up without one of her kidneys.
Lindsey Bever
OPIOID OPTICS
Wonkblog
Because epidemics are dynamic, the impact of any new policy can change dramatically over time.
Keith Humphreys
DAYBOOK

Coming Up

  • Brookings Institution holds an event on girls’ education research and policy on Wednesday.
  • Brookings Institution holds an event on the results and implications of the midterm elections on Thursday.
  • American Enterprise Institute holds an event on postelection analysis on Thursday.
  • The Food and Drug Administration holds its “Vaccines and Related Biological Products Advisory Committee Meeting” on Thursday.
  • The American Medical Association holds its research symposium on Friday.
SUGAR RUSH

Tracking the money:

Rihanna calls on Trump to stop playing her music at his ‘tragic rallies’ :