Health Care: Is It Top of Mind for Voters in the Midterms?

Inflation.  Baby formula.  Gun control.  Countless important issues are at the top of voters’ minds as the midterm election approaches.  However, unlike previous election years, many voters aren’t saying health care is the most important issue to them.  How does health care stack up against a plethora of other important issues this year, and what could change in the coming months to bring health care to the forefront of the national conversation?

What the Polls Tell Us

According to a Kaiser Family Foundation (KFF) poll conducted in March 2022, health doesn’t appear to be a leading issue among voters.  When asked to name what they think will be the most important factor when voting for the 2022 midterm election, 37% of voters cited the economy, inflation, and rising prices.  Other issues mentioned by voters include climate change (4%), crime (3%), the Russian invasion into Ukraine (3%), and the COVID-19 pandemic (2%).

With inflation having reached a 30-year high of 8.5% in April 2022, it shouldn’t be surprising that voters are naming economic-related issues as their top concern.  However, what’s unusual about the 2022 polling is that compared to previous election years, health care isn’t even close to being a top issue for voters.

In October 2020, for example, 12% of voters told KFF that health care is their top issue, making it the fourth most-cited issue.  Meanwhile, the economy was a top issue for 29% of voters, while the COVID-19 pandemic and public safety each respectively garnered 18% and 13%.

Health care was even more important to voters in 2018, a midterm election year that saw Democrats regain control of the House after flipping 41 seats.   That year, 26% of respondents told KFF that health care was their top issue, placing it third on the list of topics important to voters.  Corruption in Washington came in first place with 32%, while the economy and jobs came in second with 27%. 

Even though voters might not cite health care as a top concern now, several factors could change in the coming months that could make health care top of mind for voters come November.

  • Expiration of enhanced ACA premium tax credits.  The American Rescue Plan Act of 2021 increased Premium Tax Credits (PTCs) for Marketplace insurance coverage and extended eligibility for PTCs to more individuals, making health insurance more affordable for millions in America. However, those ACA premium subsidies expire at the end of the year, and if Congress fails to renew them, 13 million Americans will start 2023 with higher insurance premiums that they may not be able to afford.  Importantly, those impacted would start receiving notices about their premium increases in October, just a month before they’re set to vote in the midterm election.  Furthermore, higher insurance premiums would make consumers less likely to receive care, potentially resulting in a combined $5.1 billion decline in spending on hospitals and physician practice services.   Democratic lawmakers that face difficult midterm races are already sounding the alarm, it remains unclear if the Senate can pass any type of legislation before the election that includes a renewal of the ACA premium subsidies.
  • Higher Medicare Part B premiums.  The Medicare Part B base premium increased by 14.5% from $148.50 a month to $170.0 a month in 2022.  On top of this, the annual deductible for all Part B beneficiaries increased from $203 in 2021 to $233 in 2022.  When the Biden administration finalized Part B premiums and deductibles in November 2021, inflation for the upcoming year wasn’t anticipated to be much different from the usual level of 2%.  However, with inflation currently hovering above 8%, higher Part B premiums are especially difficult for seniors to absorb, and continued higher-than-average inflation over the coming months could make health care costs a more important issue for seniors.
  • End of public health emergency (PHE).  The administration has repeatedly pledged to provide 60 days’ notice before letting the PHE expire.  The end date for the current PHE is July 16, 2022, and since the administration declined to say in mid-May that it will let the PHE expire, it is all but certain that come mid-summer, the PHE will be extended through October 2022 – less than a month before the midterm election on November 8.  The end of the PHE would immediately trigger a 151-day period for temporary Medicare telehealth waivers to unwind and a 365-period for states to initiate redetermination of Medicaid eligibility for all Medicaid enrollees.  While the end of telehealth waivers and loss of Medicaid coverage for certain individuals wouldn’t occur until long after Election Day, starting the countdown less than a month before voters cast their ballots could cause some voters to consider health care as an important issue.   However, due to the potential political implications of ending the PHE in October, it seems safe to assume that the administration will ensure the PHE remains in place until after the midterm election

Inflation, foreign conflicts, and public safety are likely to continue to dominate voters’ thinking as the 2022 campaign season continues.  However, a loss of ACA premiums subsidies, pressure from high Part B premiums, and the end of the PHE all have the potential to change the calculus for some voters as they decide who to cast their ballots for on November 8.

What’s Changed for Open Enrollment 2022?

Open enrollment for 2022 kicked off on November 1, and it’s particularly consequential to President Joe Biden, who campaigned on building off the success of the Affordable Care Act (ACA) to expand access to health care coverage.  To deliver on these promises, open enrollment has undergone several key changes to make it more consumer-friendly for 2022. 

  • First off, open enrollment is a month longer than the previous four years.  While open enrollment last year ended on December 15, 2021, for the upcoming plan year, it ends on January 15, 2022.
  • Plan enrollees can also expect record-low prices, thanks to an extension of ACA premium tax credits made possible by the American Rescue Plan.  According to the Biden administration, four out of five people can now find a plan for $10 or less per month.
  • Additionally, 2022 sees a major boost to enrollment assistance.  Plan enrollees for 2022 can now look forward to over 5,000 enrollment assisters and navigators, plus nearly 50,000 brokers and agents.  Notably, the Centers for Medicare and Medicaid Services relaunched a program that engages with local organizations to provide outreach and education.
  • The current open enrollment has a new focus on health equity.  The administration is rolling out new efforts to people who previously lacked access to coverage, and advertising is being conducted in several new languages: Chinese (Mandarin and Cantonese), Korean, Vietnamese, Tagalog, and Hindi.
  • Finally, more Americans than ever will be eligible for open enrollment 2022.  That’s because three states (Kentucky, Maine, and New Mexico) transitioned from state-run coverage to the federal exchange for 2022, bringing the total number of state-based marketplaces on to 18. 

What Do These Changes Mean for Enrollment?

For plan year 2021, enrollment reached a record high of 12.2 million people, which can be attributed to a special COVID-19 enrollment period that ended in most states in August 2021.  However, many Americans seem to be unaware of premium tax credits made possible by the American Rescue Plan.  According to an October 2021 poll by the Kaiser Family Foundation (KFF), only about a quarter of adults who are uninsured or buy their own insurance checked to see if there were eligible for ACA premium tax credits. 

KFF currently estimates that nearly 11 million Americans are eligible for but not enrolled in subsidized ACA plans.  Despite a record number of enrollees in 2021, it remains to be seen if new outreach efforts, longer enrollment periods, and other changes brought into play for 2022 will be enough to attract more enrollees and continue to lower the number of uninsured individuals in America.

Why Feelings Are Mixed on the New Surprise Billing Rule

The administration’s latest interim final rule to implement the No Surprises Act dropped on September 30.  Here’s a look at the various reactions from stakeholders and why they are mixed.

What does it say?  The rule outlines a baseball-style, independent dispute resolution (IDR) process for settling payment disputes between out-of-network providers and commercial insurance plans.  Before the IDR process can begin, both parties involved must enter into a 30-day negotiation period to determine a payment rate.  If these negotiations fail, either party can initiate the IDR process. 

Next, both parties submit their proposed payment rate with supporting documentation to a certified IDR entity, who then issues a binding determination by selecting one of the party’s proposed rates.  When making a determination on which rate to select, the IDR entity must “begin with the presumption” that the most appropriate rate is the median of contracted rates for a specific service in the same geographic region.

  • Why? According to the rule, emphasizing the median in-network rate will help ensure that IDR outcomes are predictable and that stakeholders are not incentivized to overuse the IDR process.

In addition to the median-in network rate, other factors IDR entities may consider include the level of training, experience, and quality and outcomes measurements of the provider or facility that is furnished.

Insurers’ reactions have been favorable overallAmerica’s Health Insurance Plans said the focus on the median in-network rate “is the right approach” to encourage all stakeholders to work together and negotiate in good faith.  And the ERISA Industry Committee said the IDR process will reinforce the intention of the No Surprises Act.” 

But hospitals aren’t so happy.  The Federation of American Hospitals said the rule “misreads Congressional intent” on establishing a “fair and balanced” IDR process, while the American Hospital Association said the rule “unfairly favors insurers to the detriment of hospitals” and other providers. 

Reactions from lawmakers are mixed, too.  Like hospital stakeholders, comments from members of Congress have focused on the rule’s prioritization of median in-network rates in the IDR process.  Ways and Means Committee Chair Richard Neal (D-MA) and Ranking Member Kevin Brady (R-TX) said in an October 5 letter to the administration that the rule’s bias towards a median rate is not consistent with the law passed by Congress, which requires IDR entities to consider a range of factors when determining the appropriate rate. 

However, House Education and Labor Committee Ranking Member Virginia Foxx (R-NC) commented that the rule is “consistent with congressional intent.” Both the Ways and Means Committee and the Education and Labor Committee played key roles in drafting the No Surprises Act. 

When the No Surprises Act passed late last year, it was considered a win for hospitals, who favored settling out-of-network payment disputes with an IDR process.  In contrast, private health plans were advocating benchmark rates based on the median in-network rate as a solution.  By prioritizing median in-network rates in the IDR process, could the administration be attempting to balance the concerns of all health care stakeholders? 

What’s next: The administration will issue a rule later this year to implement the pharmacy and prescription drug reporting requirements of the No Surprises Act.  Despite a 60-day public comment period, the rule is final, and stakeholders will be required to comply with all of its provisions beginning January 1, 2022.  In the meantime, Reps. Neal and Brady have requested additional written justification from key administration officials on how the latest rule complies with the No Surprises Act, and stakeholders will continue to engage with the administration on upcoming rules.   

Despite Reintroduction, Medicare for All, Medicare-X Proposals Face Limited Odds

With control of the White House and both chambers of Congress, Democrats are newly emboldened to expand access to health care coverage.  A group of progressives in the House are making another attempt at Medicare for All, while moderates in the House and Senate want to expand coverage via a public option.  However, lack of Republican support for either proposal means both are likely doomed.

Medicare for All

On March 17, Reps. Pramila Jayapal (D-WA) and Debbie Dingell (D-MI) introduced the Medicare for All Act of 2021 (H.R. 1976).  The bill has so far attracted 109 co-sponsors, indicating the highest-ever level support in Congress for a national health insurance program.  While a Medicare for All bill has never advanced out of a congressional committee, advocates for single-payer feel the COVID-19 pandemic has laid bare the inefficiencies of the current health care system and made their case even stronger.  In a press release, Rep. Jayapal touted Medicare for All as a solution for the millions of Americans who lost employer-sponsored coverage because of the pandemic.    

In addition to being a total non-starter with Republicans, Medicare for All faces two major obstacles.  One is resistance from health care stakeholders, who have long thrown cold water on single-payer proposals.  The Partnership for America’s Health Care Future, a coalition of insurer and provider organizations, issued a recent statement saying Medicare for All is unaffordable and would lead to lower quality.  Additionally, the US Chamber of Commerce said in press release that Medicare for All would reduce access to providers and hospitals.

The second major obstacle comes from within the Democratic party itself.  President Biden has clearly stated his preference for expanding access to coverage through a public health insurance option, one that moderate and centrist members of the party share.  While Biden has gradually moved leftward over the course of his political career, it is extremely unlikely he would champion a health care proposal that remains divisive among members of his own party. 

Medicare X

Closer to the President’s ideological preferences for expanding coverage is the Medicare X Choice Act of 2021 (S. 386/H.R. 1227).  First introduced by Sens. Michael Bennet (D-CO) and Tim Kaine (D-VA) in 2017, this proposal would allow all Americans to purchase a public health insurance plan based on the Medicare program that would reimburse providers at the same rate Medicare currently does and allows patients to access providers that accept Medicare.  Supporters of Medicare X tout it as a more realistic proposal to achieve universal coverage that would be less disruptive to the health care system.  Additionally, a January 2020 poll from the Kaiser Family Foundation found a public option-based proposal is more favorable to a greater number of Democrats and Independents than Medicare for All.

The fact that Medicare X/a public option enjoys higher favorability than Medicare for All does not necessarily improve its odds of passage.  Medicare X is similarly unpopular with Republicans and given the party’s razor-thin control of the Senate, Democrats would likely have to use budget reconciliation to advance any kind of public option proposal.  While reconciliation was used to pass the Affordable Care Act (ACA) in 2010, it remains unclear if a proposal like Medicare X would meet the strict budgetary criteria required to be considered under budget reconciliation.  Furthermore, Congress is limited to the number of times it can use budget reconciliation in any given year, and Democratic leadership have yet to make any prognostications about what proposals it could consider under budget reconciliation in the future. 


While Medicare for All and Medicare X are unlikely to become law anytime soon, a key implication of both proposals is their potential to hasten divisions between progressive and moderate Democrats.  Since the start of the Biden Administration, both wings of the party have largely set aside their differences to advance key components of the President’s agenda, including cabinet nominations and a sweeping $1.9 trillion COVID-19 relief package.  While the House, and some argue the Democratic Party, have moved more to the left – it remains clear that moderate Democrats in the Senate maintain a high level of power over the fate of any legislation in the upper chamber.  Disagreements over health care proposals have the potential to disrupt broader legislative goals from the White House, such as immigration, infrastructure, or tax reform.