Midterm Elections Are Over: Now What?

With the 2018 midterm election still fresh and Florida again making headlines as this issue of Psychiatric News goes to press, it is increasingly apparent that the blue wave on election night was larger than it initially appeared. Democrats in the House had their best midterm showing since the Watergate and appear poised to pick up 37 to 40 seats. Republicans did better in the Senate, but what looked to be a red Senate wave ran into a blue undertow in Arizona and Nevada. Pending a runoff Senate election in Mississippi, Republicans appear to have netted two seats when they had what some have described as the most favorable electoral map in modern history. The partisan makeup aside, there will be more than 100 new members of the House and Senate to get to know.

Before the Democrats seize their first opportunity in the Trump era to wield the levers of power, the Republican-controlled Congress still has business to finish—several appropriations bills, the farm bill, reauthorization of Temporary Assistance for Needy Families, and a renewal of the National Flood Insurance Program. As Congress tries to conclude its business, eyes are also on President Trump to see whether he forces a government shutdown over building his border wall.

The good news for psychiatry is that, for the first time in 22 years, the Labor-HHS-Education appropriations bill that funds federal health programs and research at the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, and elsewhere, was enacted through regular order. So, any government shutdown, long or short, will not disrupt those programs. But if you plan to visit a national park at the end of the year, buy trip insurance to be on the safe side in case it has to close.

The congressional leadership positions have mostly been decided, with the exception of the House, where the will-she-or-won’t-she-be-speaker Pelosi drama could run for weeks. Regardless of that outcome, divided government will present new challenges and potential opportunities. Next year there will be oversight, investigations, and subpoenas, but there will also be plenty of legislating.

Legislating is a process. Much like children, significant legislation typically takes multiple years—even multiple congresses—to mature. Regardless of what crosses the finish line in 2019-2020, much of what happens during the next Congress could be a prelude to what comes afterward—on prescription drugs, health care markets, access, Medicare, Medicaid, and provider payment. And both parties will have their eyes on the high-stakes 2020 election cycle. The coming months will clarify where congressional Democrats, Republicans, and the White House may see it in their interest to compromise or to polarize.

A few early inflection points could be particularly revealing. Without a bipartisan deal, defense- and nondefense-appropriated spending face automatic cuts of 11 percent and 9 percent, respectively. The national debt limit must be raised in the spring. How the parties engage on such issues will tell us how much hope there may be for compromise and near-term governing. The stridency of each party’s base will not make it easy, but each party also has reason to cater to the middle class as the 2020 election approaches.

With health care one of the House Democrats’ top priorities, expect hearings and modest legislation on prescription drug prices, but not necessarily agreement with the White House. House legislation to stabilize the individual insurance market is also likely, but the Senate may not follow suit. The opioid crisis will continue to get attention, and APA will also be working to expand the focus to underlying mental health issues, the rise in suicides, parity enforcement, and issues like telepsychiatry.

It’s easiest right now to point to things that will not happen. Votes to repeal the Affordable Care Act (ACA) are an artifact of history—at least for the next two years. Repeal and replace is dead, as are Medicaid cuts and per capita caps. Instead, ACA and Medicaid battles will mostly be fought on the administrative and legal fronts, with House Democrats attempting to shine a light on administration efforts to undermine them. So, fasten your seatbelts. The race to 2020 and the quest for political advantage start now. ■