Midterm leverage could reshape Medicaid and ACA subsidy negotiations
Democrats may enter the next Congress with more leverage over Medicaid cuts and ACA subsidies if they gain ground in the House, according to a former member of Congress and two senior health policy advocates who expect the next major health care deal to be forced through crisis politics rather than routine legislating.
Robert E. Andrews, chief executive of the Health Transformation Alliance and a former New Jersey congressman who helped author the Patient Protection and Affordable Care Act, projected that Democrats could emerge from the Nov. 3 midterm elections with at least 225 House seats and possibly as many as 240. In the Senate, he outlined two broad paths: Democrats either win enough close contests to hold 52 or 53 seats, or they fall short and remain at 48 or 49. Either way, he expects divided government to leave lawmakers with only limited room to negotiate health policy outside of high-pressure standoffs.
“One bite a year out of the apple” was how Andrews described the pace of major legislative movement. In his view, those bites are most likely to come during government shutdown fights or debt ceiling clashes, when the threat of disruption forces both parties toward compromise.
The politics of health care rarely move in clean, orderly sequences.
Andrews argued that Democrats would have more leverage in a House majority, even if their Senate position remains fragile. He tied that leverage directly to two flashpoints: renewal of enhanced ACA premium subsidies and reversal of Medicaid reductions embedded in H.R. 1, the 2025 budget reconciliation law. If Democrats choose the ACA subsidies as their lead demand, he said, perhaps half of the Biden-era subsidy levels could be restored. If Medicaid becomes the central issue, work requirements could be dropped and additional financing could flow back into the program.
The policy stakes are concrete. Premium support determines whether individual-market coverage remains affordable for millions of enrollees, while Medicaid financing shapes access to primary care, specialty services, and hospital reimbursement in lower-income populations and in states already operating on thin margins. A rollback in either direction would not be a symbolic adjustment; it would change who can keep coverage and how providers absorb uncompensated care.
Shutdown politics are likely to drive the next health deal
Andrews was blunt about the role of President Donald Trump in any future negotiation. He described the president as unpredictable and said no outcome should be ruled out if a larger political trade becomes available. In his framing, the White House could potentially accept changes on Medicaid if it received a policy concession of comparable value, such as an extension of tariffs or a permanent capital gains tax cut.
In practice, that means the next health policy package may be less about long-range planning and more about transactional bargaining under deadline pressure. The result could be incremental rather than sweeping. Andrews said a broad rollback of Medicaid cuts is possible, but he considered stepwise changes more likely than a full reversal.
Lisa Kidder Hrobsky, senior vice president of federal relations, advocacy and political affairs at the American Hospital Association, said Democrats have been fairly clear about building an agenda around affordability, including health care affordability and broader oversight of how the administration has operated over the past two years. Danielle Turnipseed, chief public policy officer at the Association of American Medical Colleges, added that public preferences around Medicare and Medicaid differ by state and will likely shape how much traction any national agenda can gain.
Hospitals have a direct financial interest in the outcome because Medicaid policy affects payer mix, uncompensated care, and the pressure on safety-net systems. Physicians feel the impact differently but no less sharply: coverage losses often convert into delayed visits, untreated chronic disease, and more advanced disease at presentation.
PBM reform and price transparency still draw bipartisan attention
Even in a polarized Congress, Andrews pointed to two areas where he sees genuine overlap: pharmacy benefit manager reform and price transparency. He cited a recent move by the Centers for Medicare & Medicaid Services toward requiring PBMs to disclose all revenue sources, a step he said aligns with Democratic priorities. Hospital price transparency rules could also tighten, though he acknowledged that hospitals may view stronger requirements as harder to meet.
Transparency policy has become a rare point of convergence because both parties can frame it as consumer protection. The politics are simple, but the operational burden is not. Hospitals may face further reporting obligations, and PBMs could confront deeper scrutiny of rebate structures, spread pricing, and fee arrangements that have long been difficult for employers, patients, and regulators to track.
“The issue is not whether transparency sounds good; it is whether the rules are specific enough to change behavior,” is the practical reality sitting behind these proposals.
Kidder Hrobsky said the hospital field is watching closely for any momentum that could carry transparency requirements further. The challenge for providers is that compliance often requires new data infrastructure, legal review, and staff time long before any benefit shows up in patient billing or payer negotiations.
NIH funding faces uncertainty despite broad bipartisan support
Turnipseed said there is still strong bipartisan support for NIH funding, and Congress is expected to resist proposed cuts. She also warned that the way funds are released can matter as much as the topline appropriation. An AAMC analysis found that NIH funding was fully obligated in grants for fiscal years 2025 and 2026, but the agency awarded fewer grants in fiscal 2026 than in fiscal 2024. Through Aug. 31, the NIH had funded 9,714 fewer grants than at the same point in fiscal 2024, according to AAMC tracking.
For research institutions, the problem is not only the size of the budget. Delayed or back-loaded grant awards can disrupt hiring, stall lab work, and force universities and medical centers to make planning decisions without stable cash flow. Turnipseed said holding grant money and then releasing it aggressively near the end of the fiscal year creates uncertainty that biomedical research programs cannot absorb indefinitely.
“We can’t continue to see that kind of progress if the money does not make it out the door,” she said.
Andrews said a Democratic Congress would likely try to return to a more clinically peer-driven grant award process, while the administration would seek greater influence over how awards are made. He added that if Republicans keep the Senate and Sen. Susan Collins of Maine wins reelection, she could be better positioned to defend NIH funding.
The fight over research dollars reaches beyond university budgets. Delays in NIH awards slow the pipeline of clinical discovery, reduce support for early-stage investigators, and make multicenter trials harder to launch on schedule. For academic medicine, the timing of the money can determine whether a project begins on time or never begins at all.
What emerges from the roundtable is a familiar pattern with sharper edges: major health policy changes are likely to be negotiated in crisis conditions, not through calm committee work. Medicaid, ACA subsidies, PBM oversight, price transparency, and NIH appropriations all sit inside that pressure cooker, and each one carries direct consequences for coverage, access, and research capacity.