Last fall’s election captured the attention of Americans, both on the federal and state level. As the newly elected officials are taking office this month, we were interested in taking a look at how the election results could impact how 341 million Americans get health care and interact with the health care system.

On this episode of HealthChangers, host Ashley Bach spoke with the leaders of our public affairs teams at Regence: Ali Esquea, vice president of federal affairs, and Stephen Foxley, vice president of state affairs. Ali and Stephen, with decades of experience in U.S. and state politics, examine how the recent election could impact not just health policy in the White House and Congress, but in the four states where Regence operates: Idaho, Oregon, Utah and Washington.

Listen to the full podcast episode on the player above. Below are some highlights, which have been edited for length and clarity.

AB: Let’s start with the federal election results. Ali, Republicans now control the White House and both branches of Congress, but there are some limits on what legislation they can pass, correct?

AE: That's absolutely right. Passing legislation in the U.S. Senate usually requires 60 votes, but Republicans do not have 60 votes in the Senate; they have 53. So they'll be able to advance certain tax and spending legislation with a simple majority vote, but they'll need the support of Democrats to advance other legislation that requires that 60-vote threshold, and that gives Senate Democrats significant influence on what we call “must pass” bills -- things like government funding program extensions and reauthorizations.

A process called budget reconciliation, though, does allow Senate Republicans to pass some of that tax and spending legislation with a simple majority vote, and they will use that tool to pass a number of their key priorities. I think we'll see it used to advance changes to taxes, the debt limit, entitlement spending like Medicare and Medicaid, but it won't be able to be used to enact all of the Republicans’ policy objectives.

AB: Are there things that President Trump or his team talked about on the campaign trail that they won’t be able to enact because of the 60-vote threshold?

AE: There are provisions of the Affordable Care Act (ACA) that could be significantly altered through budget reconciliation, like some of the Medicaid expansion in the ACA. However, some of the insurance market reform in the ACA, so things like guaranteed issue of health policies and the exclusion on pre-existing conditions, cannot be changed with reconciliation; that would require 60 votes. That's why we don't think that any repeal to the Affordable Care Act is likely in the upcoming Congress.

AB: What will be the health care policy priorities on the federal level?

AE: This year is going to be a major year of tax policy debate, and President Trump has also made significant budget cuts a priority. Health care reforms may be secondary to some of those goals, but they're definitely going to be on the table to help pay for some of the tax cuts or to achieve those reduced spending targets.

President Trump has said he's not going to revisit the “repeal and replace” debate over the ACA, but I do think that we could expect some changes and some policies, looking at risk pools and reinsurance, and I think it also makes it a lot harder to extend enhanced ACA tax credits. These are the credits that lower the premiums for people who are buying their health care on the marketplace. They expire at the end of 2025.

One of our key priorities at Regence, along with others in the health care insurance industry, is advocating to keep those tax credits. These credits really benefit everyone, especially red states that haven't expanded Medicaid. If the credits expire, it's estimated that 20 million people will see their premiums go up, and that increase could be anywhere from 25 percent to 100 percent. We also expect about 4 million people across the country could lose their health care.

In other potential legislation, some Republicans are advocating for capping the income tax exclusion for employer-sponsored health insurance coverage. We're working with our trades and union groups to really advocate against this, because we know that it's going to ultimately increase premiums and reduce benefits for employers and their employees.

AB: Ali, thank you for your insight of the upcoming federal landscape. Stephen, I wanted to switch gears to the political picture in the four states where Regence operates. Let’s look at Idaho and Oregon first.

SF: Idaho will have a stronger Republican majority in both the state House and state Senate. It's a bit of a different brand of Republicanism. We get more of a mix of what I would probably consider a kind of traditional, business-friendly type Republican, and then the kind of newer Republicans, who tend to be more populist, more focused on issues that impact small business. These could include insurance issues that haven't typically come up in Idaho, like in the pharmacy benefits space and protecting our smaller local rural pharmacies and providers.

In Oregon, for the next two years, we'll have super majorities in both the House and in the Senate. In Oregon, you can't raise taxes without a super majority, and so some of those revenue measures will get some extra looks this year. One area where it could impact Regence and other payers directly is a premium tax that's used both to support Medicaid funding, as well as a re-insurance program in the individual market that helps keeps premiums lower for people that are buying their own insurance through the healthcare.gov site. That's up for sunset extension or to remove the sunset, and Oregon Gov. Tina Kotek’s most recent budget came out to maintain that tax support for the next few years.

There are also going to be a lot of provider-focused bills in many of our states, I would just point out that in Oregon in particular, something that Regence will be looking at is the prior authorization process; we want to make sure that we're removing that burden for providers as much as possible, while still making sure that our members have access to safe, medically appropriate and necessary care.

AB: What about Utah and Washington?

SF: In Utah, Gov. Spencer Cox was re-elected, and he has had a focus around health care; he created something called the One Utah Health Collaborative, which really is trying to lower the trajectory of health care cost growth so that it grows no faster than wages or inflation or the overall economy. We're optimistic about some of these things that he's supported in the past.

In Utah, legislators may address ground ambulance rates. Utah has some of the highest rates in the country. At Regence, we certainly want to make sure that our members are protected when they need an ambulance to get to the hospital or between a hospital and another medical facility when it's medically necessary, but we want to make sure that those services are delivered at an affordable and fair price for our customers.

Washington, meanwhile, will be in a different budget position than some of our other states. They are estimating a $10 billion-$12 billion budget shortfall over the next four years, which means that they're going to have to take a harder look at potentially cutting programs or revenue measures to try and fill that gap. But there will be a real focus on, how can the state address health care spending? One thing that they're looking at would be to have a rate cap for what public employees and state employees pay for hospitals. One of the things that Regence will want to make sure is protected is that, to the extent there are savings there for state employees, we do want to make sure that it doesn't come at the expense of higher costs for our individuals and small businesses in Washington.  

AB: Stephen, we see the election results change year to year, but there are issues that endure. What are some of the long-term issues that Regence is focused on in the states?

SF: Our number one focus is always going to be around affordability and making sure that the decisions that state policymakers are driving toward make health care better and more affordable for the members that we serve.

Another evergreen issue is around pharmacy. Pharmacy benefit managers have received a lot of scrutiny at a federal level and also at our state level. One of the areas that has been looked at is reimbursement for community pharmacists and retail pharmacists. So, we'll be seeing potential legislation or regulatory activity there in 2025.

And then one of the things that we look really closely at is around our specialty drug spending. We have about 3 percent of our prescription drug claims that drive more than 60 percent of our spending, and this is something that policymakers have looked at, too. We're looking at this on the medical benefits side, with some of these provider-administered drugs and making sure that they aren't, in addition to the really expensive cost at a baseline level that these drugs have, that there's not an excessive markup as part of the administration of them. 

Another area that we've looked at is around some of these really tough contract negotiations and making sure that providers and insurance companies aren't putting the public in the middle. At Regence, we're doing everything we can to hold the line on costs, but we don't want to be unnecessarily scaring a member with a letter that either we need to send or that a provider preemptively sends. If we're working together, we want that to happen as much as possible behind the scenes while we reach a deal, so that those communications don't go out unnecessarily.