Katie Keith (KK): Good morning.

Dan Gorenstein (DG): Good morning. How are you?

KK: I am tired.

DG: Tired but tired. But awake. Yeah.

KK: But, you know, waking up to a whole new reality. Way different than I ever anticipated.

DG: Is that right? 

Yeah. Like in one word this morning you’re feeling?

KK: I mean, mystified.

DG: Mystified.

KK: It’s like, wow. it’s just way bigger of a wave than I personally expected. Like we’re waiting on the Mississippi Senate race.

DG: Yeah. Whose bingo card was that on?

Some people are calling the ’26 midterms a ‘Blue Tsunami,’ others a ‘Democratic wildfire.’

Whatever you call it, Democrats will have big majorities in the House and the Senate for the remainder of President Trump’s second term — a dynamic that could have major implications for health policy over the next two years and beyond. 

Today, a conversation with Georgetown’s Katie Keith on Democrats’ health care affordability agenda in Washington … and what Dems’ strong showing could mean at the state level. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

KK: I’m Katie Keith, I’m the director of the Center for Health Policy and Law at Georgetown Law and a contributing editor at Health Affairs, where I help write the Health Policy at a Crossroads series.

DG: Katie has been following health policy for nearly two decades, including a stint working in the Biden administration.

We called her up on Wednesday morning to get her take on what this week’s election results might mean for health policy.

So, Katie, there was a lot of talk this year about health care being on the ballot. 

Democrats hammered Republicans for cutting nearly $1 trillion over the next decade out of Medicaid and refusing to renew enhanced subsidies for people who buy insurance through the Obamacare marketplaces.

Those moves are estimated to push some 14 million people off their health coverage in the coming years.

How much do you see this wave as a repudiation of the president and the Republican congressional health care agenda?

KK: I mean, I think it played a hugely significant role. I think there’s no denying that. And at least the way I think about the healthcare debate is in the context of overall affordability. And this was, you know, an election hugely focused on people’s economic struggles at the moment.

I think healthcare is amongst gas and groceries and the things that people think about when they think about the affordability crisis.

DG: Overall costs. Right. And, you know Democrats have pledged that in the first 100 hours of a new Democratically controlled House, they will pass bills to one, reinstate the enhanced ACA health care premium subsidies; two reverse the cuts to Medicaid. Do you think the Democrats could get enough Republicans, including President Trump, on board with either of those? I mean, last night, the president said he wants to work with Democrats.

KK: I think it depends, I think there will be multiple ways that policy making is done. So I would fully expect, you know, take the Democratic leadership at their word. They will do those bills in the first 100 hours, 100 days. Whether the president signs those bills or they get 60 votes in the Senate, you know, it really depends on how they are written. And there will be these other major inflection points for must pass legislation, appropriations legislation.

DG: The normal course of business.

KK: The normal course of business, that sort of, forces deals to get made. That could be where, you know, maybe it is not everything that is in these 100 day or 100 hour bills, but do you get elements of, you know, restoring enhanced premium tax credits?

And there’s some strange bedfellows with even Republican support for things like delaying the cuts on the provider taxes and cuts to hospitals, that kind of thing. And what is the trade that could bring a, you know, President Donald Trump along to agree to that? 

DG: What I really hear you saying here, Katie, is that with Democrats in control of both chambers, it puts these issues, the Medicaid cuts, the ACA enhanced subsidies, into play. And if the Republicans had won, we would not be talking about that today.

KK: I think that’s right. And whether those get across the finish line is an open question, but it will continue to be a high agenda item on health care. And I would say especially on prescription drugs, where this white House has leaned in so heavily. For example, the Trump administration You know, they have really embraced Medicare drug negotiation, which was a policy passed by Democrats through budget reconciliation. And they’ve made it their own and they’ve leveraged it.

I think Democrats would be delighted to expand that policy, not just for Medicare, but to the entire commercial market. Is there enough support in Congress to do that? Is that something that the president would support? It could be.

I have no idea. But it wouldn’t sort of take it off the table in any way. If there was a big win on prescription drugs for the American people. 

DG: So there have been a lot of people saying on Twitter and whatnot, oh, this reminds me of 2006, you know, the tee up to what became the window for the creation of the Affordable Care Act. Obamacare. Do you see whatever happens, even if nothing ends up passing as a kind of a tee up to a new major health reform era?

KK: Yeah, absolutely.

DG: Absolutely. I’m a little surprised that you say absolutely. 

KK: Well, I think that will be the exercise. I think you can see that even in, you know, Democrats on the Senate Finance Committee have put out a several, but the one I’m thinking about is on private health insurance, a really extensive request for information to do exactly what you’re saying and sort of seed the next generation of health reform ideas.

There’s a real recognition that the status quo was also not sustainable and that people are unhappy. This is sort of the time that you go through this process and put pen to paper and have hearings and markups and really build, I think, using the bully pulpit and the platform to show that, you know, Congress hears the concerns of the American people and is doing something about it. And then you are sort of teed up for a 2028 presidential election. And then you. You see what happens.

DG: So this election, as you know, means that Democrats will also have a lot of legal power. Ron Wyden of Oregon, one of the party’s Senate leaders on health care, wrote on social media, on election night. Just one word. Subpoenas. Our friends at STAT news wrote, after the election, that Democrats will be able to, quote, compel testimony and documents in their oversight investigations, a power that could affect administration officials and leaders in private health firms alike. Katie, you’re a lawyer. Is this a big deal?

KK: I think it is a big deal. Yeah. I think the ability to conduct oversight is going to be significant — subpoenas, hearings, right. I think being able to call people into Congress and get answers, I think is and even just bring transparency to what has happened or what’s about to happen, I think can be a tremendous tool.

Those tools can be used against the administration. They can also be used against, you know, sort of the, the private sector. For example, could you use a subpoena against a drug manufacturer to try to get a copy of the deal that that drug manufacturer made with the white House on most favored nation? 

DG: Most favored nation, of course, being the term for deals the administration has cut with more than two dozen drugmakers to, among other things, charge state Medicaid programs less than they charge in other developed countries … deals whose specifics have been kept private.

And when it comes to oversight of the administration itself, we know that these new Democratic senators, Annie Andrews in South Carolina, Abdul El-Sayed in Michigan. They’ve talked a lot about going after RFK Jr and his changes to vaccine policy. Do you think a Democratic Congress might be able to force any changes on vaccines here?

KK: I’m not sure about forcing changes. You know, you could definitely see hearings from the individuals who have been fired from the Advisory Committee on Immunization Practices to lift up some of the alleged abuses that we’ve seen by the administration on whether it’s vaccines or other topics as well.

I think the transparency, the sunlight, the ability to keep this issue high on the radar when it’s an issue now so many Americans care about. I think could be important in and of itself. 

DG: So we’ve been really interested in the Trump administration’s cuts to health care research. They have slashed the staffing and cut more than 100 grants at the agency for Healthcare Research and Quality, for example. This is a small agency often called AHRQ, that funds a lot of research on patient safety, access to care, lowering health care costs. Of course, I know you know AHRQ well. Could a Democratic Congress with big margins force the administration to restore some of that funding?

KK: They could certainly direct a lot of the funding. I think there, you know, continued legal questions about what happens if the administration then doesn’t spend the money in the way that Congress has directed? It’d be hard to say there’s a guarantee that it would work exactly the way Congress wants it to.

However, I think with Democrats in both chambers, there could be more accountability, including through potential lawsuits. So one example, like off the top of my head is when, you know, then speaker, Republican Speaker John Boehner sued on behalf of the House of Representatives, the Obama administration over, you know, a major Affordable Care Act policy related to how federal spending happened. And the argument was that the White House had taken over Congress’s sort of fundamental power of the purse. There. And they actually succeeded in that litigation.

DG: So we’re talking about legislative oversight, right? This new legal power, but also there’s confirmations. Katie, what can we expect there? I mean, I could imagine And I’m already reading a little bit the morning after the election about Republicans trying to get some nominations through in this lame duck Congress. What are you expecting both with the, the final days of the current Congress and then going forward in 27?

KK: Yeah, I think this is going to be a quite significant check. Because the Senate confirms, you know, high ranking federal officials, judges, Supreme Court justices, it is a really important authority that the Senate has.

And I think even the Trump administration, now with Republicans in control of the Senate, has faced some headwinds and I would still expect, you know, in the time they have left in this Congress an attempt to push through whatever, you know, judicial and HHS and other nominations that they have pending. And whether that means they will moderate in who they nominate or just leave those, you know, seats open is going to be very interesting, you know, the changes to judges who are appointed for their lifetime has implications that extend far beyond, you know, the election cycle itself. So I think this is quite significant.

DG: When we come back, we zoom in at the state level, as voters weighed in on abortion and transgender health care, and the impact the election might have on how states implement massive changes to Medicaid.

BREAK

DG: Welcome back. We’re unpacking the results of the midterm elections and how the results will impact health policy in the years ahead with Katie Keith. Katie is the director of the center for Health Policy and the law at the O’Neill Institute at Georgetown, and an eagle eyed observer of health policy in Washington. Nice to be described as a bird, Katie?

KK: Could be a lot worse, Dan.

DG: As we were preparing for this interview, you said that while federal races tend to get the most attention, the most direct impact of health policy will be at the state level. Two issues you follow very closely — abortion and transgender health care — were up in several states, and I’d like to start with abortion. Voters in Virginia, Missouri and Nevada reaffirmed their support for abortion rights. But in Idaho, they voted decisively to retain the state’s ban on abortion. What do you make of these results?

KK: I mean, I think other than Idaho, it’s actually quite consistent with what we’ve seen on past ballot measures. Reproductive health access abortion in particular, is a popular issue with bipartisan support. Like people really do fundamentally think that women and their doctors should choose, not the government.

And so it’s definitely not a surprise to see Missouri reaffirm what voters chose back in 2024. Ditto for Nevada. And frankly ditto for Viriginia who was taking this issue up for the first time. That said, it was not a clean sweep and not the case in Idaho where one of the nation’s most extreme abortion bans remain in place following this election.

DG: Do you expect that we’re going to continue to see these sort of ballot measures at the state level going forward? Like how will how do you expect, people who want to restrict abortion read these results.

KK: They might read it in two ways. One, they might think that, you know, if only the Trump administration had been tougher on this issue, they would have performed better. Uh, the other is I think that the movement will continue to try to use the courts to undermine abortion access nationwide.

And so I’m tracking many, many lawsuits against the Food and Drug Administration to try to, you know, restrict access to medication abortion nationwide. Watching litigation over, you know, so-called shield laws about, you know, can you get medication abortion even in states with an abortion ban? Those kinds of things. So I think the fight will continue with the courts. I don’t know that anybody in that movement will be cowed by the results that we saw yesterday.

DG: Looking now at transgender health care, this is obviously a topic that the Trump administration and Republicans have really leaned into.

Half of states already ban gender-affirming care for transgender kids. That generally includes hormone therapy, medications to pause puberty and surgeries.

Missouri is one of those states, but voters there on Tuesday rejected making that ban a part of the state’s constitution. And a measure to ban just gender-affirming surgeries in Colorado is currently winning, but it’s still too early to call. Takeaways at this point?

KK: No takeaways. And I guess I just think that this issue has to also be understood in the broader context of the Trump administration’s very aggressive focus and attempt to bring a lot of attention to this issue, which affects a very small number of people and, you know, their aggressive work to try to ban this care nationwide. It seems like, at least in Missouri, voters were not swayed. We’ll see what happens in Colorado too. I guess it could be something that that movement continues to push forward on different ballots in other states. I’m not sure. It feels a bit too early to say.

DG: The biggest health policy story in 2027 is likely to be the major changes coming to Medicaid. We talked about how lawmakers in Washington might handle this, but I’d like to look at it from the state’s perspective. Democrats gained complete control of state governments in at least five states. They won a bunch of gubernatorial and attorney general races, including  Republican strongholds in Texas, Ohio, Georgia and Iowa. What impact will these outcomes that we’re seeing have on these historic changes to Medicaid? I mean, I’m guessing profound.

KK: I think it could be very profound, especially in, you know, Iowa and Ohio, states with Medicaid expansion, who would be subject to these big changes that you mentioned happening in 2027. Will those attorneys general ask to join the successful Democratic attorney general lawsuit last week where you had a judge in Massachusetts say in the plaintiff states who challenged, you know, the Trump administration’s rule on this, you get a, you know, sort of a grace period for six months in the medical frailty definition that the Trump administration tried to put forward that was much narrower than the statute no longer applies.

So even there, you could see sort of quick, you know, to the extent that those states join that litigation, there could be some relief happening in those states that wouldn’t have otherwise happened, not relief from everything, but from, you know, some of the more burdensome things that the Trump administration tried to do. And then I think on the gubernatorial side, thinking about Iowa and Ohio, it could be a completely different approach to implementing Medicaid work requirements, eligibility. Redeterminations. Right. All within the constraints of the law, but it could be fundamentally different. 

And then, you know, this is less about the kind of One Big, Beautiful Bill Act, but watching a Democratic governor in Texas and in Georgia where, you know, and Wisconsin especially, I think, Wisconsin, they captured the legislature. So Wisconsin has not had Medicaid expansion, and so does that open up entirely new avenues there? And those are the states where we have results so far. I think there could be more as we kind of learn more over time.

DG: I mean, when it comes to Medicaid expansion, right? I mean, there’s a world depending on these legislative totals. There’s a world where Georgia, Wisconsin and Texas expand Medicaid, right?

KK: I mean, there could be. I think my understanding is, you know, Texas Democrats could take back one chamber. I don’t know what then the negotiation would be, but all of it becomes way more possible than it was before. So the fact that you could even say maybe it’s something to look at is, was not something I was necessarily expecting to say the morning after.

DG: Back to your word “mystified.”

KK: Back to mystified. 

DG: It really sounds like Medicaid writ large is where we could see a lot of action in states over the next few years. 

KK: I think that’s right. You are entering a period of such deep uncertainty for the Medicaid program. We have never pulled $1 trillion out of Medicaid before. And there are these huge new requirements to be implementing that most states will have to be working on. And it’s all coming at the same moment as a budget crisis. And so watching how states navigate this, including states with new leaders, you know, chambers that have flipped at the state level, I, I think it is the big question for me. 

DG: Katie. Keith, thanks so much for taking the time to talk to us on trade offs. Really appreciate it.

KK: Thanks for having me. 

DG: I’m Dan Gorenstein, this is Tradeoffs.