By Allison Evans, assistant managing editor

It seems like only yesterday the country was embroiled in a tug-of-war to determine the country’s next leaders. While the 2016 election is now a historical fixture, it should not detract from what looms ahead: The 2018 midterm elections. The midterm elections will take place Tuesday, Nov. 6, 2018, and have the potential to monumentally influence health care policy on both state and national levels for years to come. 

Federal government: Current state of affairs

Republicans control both the U.S. Houtse and Senate. Republicans edge out Democrats in the Senate, 51 to 49, while Republican margins are wider in the House — 240 Republicans to 194 Democrats.

“When the margins are this narrow, it can be hard to get anything done,” said Michelle Mathy, assistant director of political and congressional affairs at the AADA.

In the Senate, even a narrow majority can be advantageous for passing legislation through budget reconciliation, which requires only a simple majority rather than the 60 votes normally required to bring legislation to a vote. (This is how the Tax Cuts and Job Acts of 2017 passed.)

The House operates by simple majority rules, meaning that legislation can pass on a more partisan basis. Regardless of which party controls the Senate, if the margins remain narrow, it may force the parties to compromise if they want to get legislation passed, said Christine O’Connor, associate director of congressional policy at the AADA.

Party of favor: What could be

Many analysts are favoring the Democrats to win back the House after the midterm elections. Mathy agrees. “You don’t really know what’s going to happen, but as of right now, there is a belief that Democrats will take back the House.” A Democratic victory in the House means that Republicans would lose their ability to send bills to the President with their party’s votes alone. Even if Democrats pick up additional seats in the Senate, they would need to maintain all 26 of their seats and flip three more in their favor to gain the majority. While not impossible, a Democratic Senate seems to be the less likely outcome.

“In contrast to many media reports, there seems to be a trend for moderates working together from both parties on a bipartisan level on health care issues,” said Sabra Sullivan, MD, PhD, chair of the AADA’s Council on Government Affairs and Health Policy. “I don’t think our country can take much more polarization. Particularly in medicine, the inroads that we’ve begun to make have shown the issues that exist in our health care system that need to be addressed. These will need to continue to be dealt with by our House and Senate across the aisle regardless of who is in the administration.”

Anyone watching the news this past year knows there are investigations underway; however, if the Democrats gain control over either chamber there may be a more aggressive stance on investigations into the President. “The big question is, will there be a movement to try and impeach the President?” said O’Connor. The drain on Congress’s time and resources would likely stall other legislation and distract from everything else, she noted.

If, on the other hand, the party balance remains the same and Republicans maintain control of both chambers of Congress, the GOP could make another attempt to repeal the Affordable Care Act (ACA) through budget reconciliation (the last repeal was one vote shy of passing in 2017, with the late Sen. John McCain casting the decisive vote to defeat it).

“Even when all of the levers of power have been controlled by one party, the amount of change was not as great as we expected in the health care arena,” said Murad Alam, MD, chair of the Academy’s Congressional Policy Committee.

The issues

Numerous polls and surveys conducted this year have shown that health care is consistently a top issue for voters when it comes to voting in the midterm elections. Fortunately, many of the health care issues facing dermatologists are bipartisan, with the ACA being a notable exception.

ACA, indoor tanning tax

According to AADA staff experts, it seems that ACA repeal may not occur in the near future. “While the AADA advocates against certain parts of the ACA, it also supports parts of it — like the 10% excise tax on indoor tanning,” Mathy said. If the Senate margins remain narrow, as they are now, there will most likely not be another full repeal effort, Mathy said. Instead, the focus will be on chipping away at pieces of the law.

On a positive note, a Democratic House would likely end the attempt to repeal the indoor tanning tax, which is part of the ACA. “Interestingly, even Republicans in Congress who support skin cancer prevention efforts don’t view the tanning tax in that way; they see it as something strictly affiliated with the ACA,” O’Connor said. “If the Republicans maintain the House, I think we’ll see continued efforts by the tanning industry to repeal it.”

Dermatologists and skin-safety advocates want to shift opinions about the tax. “This is not a general tax on an industry, it’s a tax for education — for educating people on the dangers of indoor tanning,” said Lawrence Green, MD, chair of the Academy’s State Policy Committee. “This consumer tax is a clear signal from the federal government that indoor tanning is a dangerous and potentially lethal activity that Americans should avoid,” wrote Bruce Brod, MD, deputy chair of the Academy’s Council on Government Affairs and Health Policy, in Cutis.

MACRA

The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) — the law that created the Quality Payment Program — passed on a bipartisan basis so there is an interest in making sure that it succeeds. Despite the frustrations and additional burdens caused by aspects of the law, it looks like it’s here to stay, although the Centers for Medicare and Medicaid Services (CMS) is trying to alleviate administrative burdens as it can, O’Connor said.

“The idea of value, not volume — those are bipartisan issues so even if the House or Senate flips, we could not expect that MACRA would be repealed,” agreed Dr. Alam.

Drug access, availability

However dermatologists feel about the President personally, his focus on regulatory relief will most likely prove beneficial, Mathy said. Recently, drug pricing has become a hot-button issue in Washington, D.C. People want pharmacy benefit managers (PBMs) to provide greater transparency in pricing, remove roadblocks that prevent generic pharmaceutical manufacturers from getting samples of brand drugs to create alternatives, and remove ‘gag clauses.’

Gag clauses are provisions in contracts between a PBM and pharmacy that prohibit pharmacists from informing patients about less costly payment options or prescription drug alternatives. As a result, patients may pay more for their prescription medications than necessary because pharmacists are prohibited from informing patients that the cost may be less if purchased without insurance than the insurance co-pay. “Patients have a right to know how to obtain their medication in the most affordable way,” said Albany. “The use of gag clauses doesn’t make any sense and is not saving patients money.”

The midterm election will not have much impact on issues like compounding as FDA Commissioner Scott Gottlieb, MD, has been receptive to concerns about access and is generally well liked by both parties. “There is an inclination by Congress to defer to the FDA commissioner to continue his efforts in issuing guidance and regulation on issues about compounding,” O’Connor said.

Compounding resources

Check out the Academy’s compounding toolkit at staging.aad.org/practicecenter/compounding.

State legislatures: Current state of affairs

Historically in midterm elections, the party in power loses seats, said Dr. Green. Recent polls suggest this may prove true once again, which could shift the balance of power between Democrats and Republicans on the state level.

Drug access, indoor tanning

Despite the partisan battles taking place, many of the Academy’s state-level issues are bipartisan, said Lisa Albany, JD, director of state policy at the AADA. “With step therapy, for example, we are saying to state legislators, ‘This effort is not to prohibit the use of step therapy, but what we want to do is have guardrails on its use,’” said Albany. The AADA works to show that often the use of step therapy can actually increase health care spending when patients cannot access the medications they need, and this resonates with some policymakers.

Historically, indoor tanning regulations were typically more favorable with Democrats; however, in recent years, Texas, Louisiana, and other “red” states have passed indoor tanning legislation. But in Maryland, a “blue” state, passing similar legislation has been a challenge; as a result, the AADA has been working on a county level and has passed bans in four counties.

Indoor tanning youth access laws

For an expanded, up-to-date overview of state indoor tanning youth access laws, visit staging.aad.org/YouthAccessLaws.

“I don’t think we as dermatologists necessarily have issues that are strictly Republican or strictly Democrat. We can find something in every issue that either side will see positive aspects of. Our goal should be working with the candidates before and after elections, and developing and nurturing those relationships,” said Dr. Green.

Scope of practice

For scope of practice, the challenge is to educate legislators that expanding scope of practice does not alleviate access to health care — an argument often made by non-physicians. “When you look at a map of provider distribution, non-physicians have not moved to rural settings,” Albany said. Democrats tend to be supportive of expanded scope of practice. However, Republican legislators from largely rural states are also concerned about access to health care, and they may be more inclined to expand scope of practice for this reason, she said.

“We want these patients to be accurately diagnosed and treated,” said Dr. Green. “There’s a big difference between expansion into underserved areas and expansion of good, quality care in underserved areas. Providing good, quality care is much more important than providing care in general.”

Sunscreen ingredients

Another issue AADA staff expects will come up next year is legislation banning the sale of certain sunscreen ingredients, like oxybenzone and octinoxate, as was done in Hawaii this year (effective in 2021). “It will be interesting to see if this becomes more of an issue that Democrats side with or Republicans. Or maybe it won’t make a difference. I’m not sure how it will play out, but I think it’s something that our physicians have to be prepared to address with their patients,” Albany said. Regardless of individual or societal views on this issue, it allows dermatology to hone in on its message of protecting skin from the sun; it may also help the push to get new sunscreen ingredients approved in the United States.

Sunscreen basics

Check out the Academy’s patient-focused infographic on sunscreen ingredients at staging.aad.org/sunprotection.

At the state level, the midterm elections provide an opportunity to establish new relationships with policymakers. “When you look at the term limits at the state level, you’re going to have all of these new legislators not experienced with health care, and it’s a great opportunity for our doctors to serve as a resource for legislators who don’t really know our issues very well,” Albany said. “Regardless of the results of the midterm elections, our issues are staying the same because these are things that our members care about right now.”

Lines are drawn…through 2030

In addition to two-year election cycles, this midterm election in particular will have a significant impact down the road as it will determine a large number of legislators who will take part in redistricting, which will occur in 2020 after the U.S. Census has been conducted. Redistricting is the legally required process in which districts for the U.S House and state legislatures are redrawn in order to create districts that are as equal as possible.

More than half of the state elected officials deciding new district lines in 2020 will be elected this year, found a study by the National Conference of State Legislatures. What does this mean right now? Whoever is elected in November at the state level will play a critical role in drawing new district boundaries, which will impact future state elections and congressional district lines — and subsequently health care issues, O’Connor said. These district maps will be cemented through 2030.

Yes, the election this November is important here and now, but the effects may be felt for another decade. Regardless of experience, it’s important for dermatologists to get involved. Dr. Green recommends starting out on a state level by joining your state dermatology or medical society. “In a way, state level politics is something that we can more readily influence. Many laws that we, as physicians, practice under are based on state laws, and state legislators tend to be much more accessible than federal legislators,” Dr. Green said.

“The physician community, particularly dermatology, has learned to be an effective team. We look at what we need and what’s realistic, and put the mechanisms in place to convey that — and we’re doing a great job,” Dr. Sullivan said.

While the results of the 2018 midterm elections may not radically alter the way dermatologists practice right now, anyone who has ever played Jenga knows that every move matters. Each new relationship forged, meeting attended, hearing testified at, letter sent, phone call made, fundraiser held, vote cast — all of these things keep issues important to dermatologists and their patients locked strongly in place for the win.