Some late-night thoughts on how yesterday's election will impact healthcare policy.

OK, it's 3:00 in the morning, and I've been running around either canvassing, phone banking, attending various election night events or simply watching/tweeting about the results as they came in from around the country as well as here at home, so forgive me if this is kind of disjointed and scattershot. I'll have more coherent thoughts in the coming days...after I've gotten some sleep and recouperated.

Michigan:

• With Gretchen Whitmer winning as Governor, ACA Medicaid expansion is mostly safe for the next four years. Unfortunately, it looks like the Dems will come up short in both the state House and Senate (though they made impressive gains in each), which probably means a stalemate on the issue.

• The net effect will likely be that the just-passed work requirement law will end up going into effect after all starting January 1, 2020, which will almost certainly lead to tens of thousands of Michiganders losing coverage anyway, unless Whitmer is somehow able to convince a still-GOP controlled state legislature to modify the law back to where it stands today.

• Of course, it's also conceivable that CMS won't approve of the work requirement waiver or that it will be blocked by a judge along the lines of what happened in Kentucky last summer. If that happens, the state would have to submit a new waiver, or Medicaid expansion would end completely effective January 1, 2020. I'm 99% sure CMS Administrator Seema Verma will approve the waiver, but I figured I should throw it out there anyway.

• Whitmer's also gonna have a tougher time passing many of her other healthcare priorities, of course, although my guess is the reinsurance proposal will go through; other split-party or even GOP states have been unusually successful with reinsurance waivers, including Alaska, Minnesota, Maryland and even Wisconsin, so this probably won't be a problem.

• A few months ago I posted an Open Letter with 26 healthcare policy recommendations for Michigan (most could apply to any state, really). Of those, some should still be quite feasible (especially many of the first 12 "protections" bullets, since the GOP is already catching tons of heat over that and won't want to be hit even harder on the issue in 2020). Of the rest, I've already talked about Medicaid expansion and Reinsurance for the individual market. What I don't see happening are things like the individual mandate being reinstated, a state-based ACA exchange being established, or most of the other repairs/strengthening suggestions I listed.

Other States:

• Wisconsin: Tony Evers has narrowly defeated Scott Walker, but the GOP controls both the House and Senate...and CMS just approved Walker's own work requirement Medicaid expansion waiver as well, except for standard Medicaid, since WI never fully expanded the program. It's even possible that the work requirement approval just days before the election was the thing which put Evers over the top, though I'm sure the election junkies will clear that up soon enough. I don't know enough about how Wisconsin's waiver works to know whether or not Evers can do anything to stop it from going into effect.

• Idaho, Nebraska, Utah: All three states had their own ACA Medicaid expansion ballot initiatives...and all three appear to have passed! If those results hold, that's another 300,000 people who will be added to the Medicaid rolls next year!

• Montana: Unfortunately, it looks like the tobacco lobby managed to strangle Medicaid expansion for 100,000 enrollees (it's actually already been in place for a few years, but had a sunset provision without additional funding).

• Kansas: A Democrat just won the Governorship (!), which makes Medicaid expansion in KS very likely. It actually passed the state legislature last year but was vetoed by ultra-right-wing nutcase Sam Brownback. If so, Avalere Health estimates around 136,000 people could be eligible for the program.

• Maine: Maine actually did expand Medicaid under the ACA via a ballot initiative last year, making around 70,000 people eligible...but due to outgoing Governor LePage being a total jackass, it still hasn't been implemented. With newly-elected Democratic Governor Janet Mills, this will hopefully be taken care of ASAP.

• Florida & Georgia: Ouch and...maybe ouch? Hopes were high for Andrew Gillum and Stacey Abrams to take over the Governor's offices of both of these states, but Gillum has already conceded, while Abrams...hasn't, since it may move to a runoff election, and since her opponent, Brian Kemp, is up to his ears in likely illegal voter suppression activities (he's currently the GA Secretary of State). Abrams may pull off a win after all, but if she doesn't, Medicaid expansion is likely out of reach for both states for another four years.

• Illinois: With a newly-elected Democratic Governor (J.B. Pritzker), I'm hopeful that the state will pass some of the suggestions I listed for Michigan, including reinsurance, a bunch of patient/pre-existing condition protections, possibly establishing their own ACA exchange and so forth.

• Nevada: With Democrats taking over both the Governor's office as well as the state Senate to join the state Assembly, is it possible that they'll beat New Mexico to the punch with a Medicaid buy-in law? Remember, state Assemblyman Mike Sprinkle introduced a bill to do this a year and a half ago which amazingly managed to pass both the state House and Senate in short order...only to be vetoed by outgoing GOP Governor Sandoval.

• New Mexico: On the other hand, New Mexico also just picked up a new Democratic Governor as well! NM is well on its way towards a more thought-out version of a Medicaid buy-in proposal (thanks in large part to my friend Colin Baillio and his colleagues at Health Action New Mexico). Certainly having a Democratic Governor will be helpful...

NATIONALLY:

• Honestly, the Elephant in the Room (pun intended) is still what it was a week ago: The looming decision on the asinine #TexasFoldEm federal lawsuit, and where it goes from there. Right-wing Judge O'Connor is expected to issue his decision any time now (especially now that the midterms are over). He might announce it tomorrow. He might hold off until December 16th (after the 2019 Open Enrollment Period is mostly over, though some states have extended deadlines).

• Other than that, the split decision with the Democrats retaking the U.S. House and the Republicans adding to their numbers (if only by a few) in the Senate pretty much guarantee a stalemate on any legislative action when it comes to healthcare...positive or negative. The ACA is mostly "safe" for the next two years...but it's not going to see any desperately needed improvements either. It'll sort of hobble along at the federal level as it is now...except with Trump's executive orders and HHS/CMS appointees screwing around with it via regulatory actions (primarily things like the expansion of #ShortAssPlans), which is exactly why it's so vital that the states which are able to lock in ACA protections themselves do so.

There's a whole mess of other stuff as well, but it's now 4:18am and I'm about to drop.