GOP state gains expected to have broad impact on physicians

Republicans on Nov. 2 gained control of nearly 700 additional state legislative seats -- the biggest gain by either major party in one election since 1958 -- moving medical liability reform, abortion and conservative issues higher on some state legislative agendas.

Republicans picked up at least 19 state legislative chambers once controlled by Democrats. The GOP now has majorities in 25 legislatures, the Democrats have 16, and the rest are split, remain undecided or are nonpartisan, according to results reported by the National Conference of State Legislatures. Republicans gained a net of five governor's offices, giving them 29 while Democrats have 19. Rhode Island's governor is independent. On Nov. 29, Minnesota election officials will begin recounting the results in the governor's race because the Democratic candidate won by less than a percentage point.

This Republican wave was not driven by concerns about the health care law as much as it was by worries about the economy and a typical midterm reaction against a sitting president, according to policy experts and polls on the issue. The bottom-line impact of these Republican victories won't be clear until new governors and lawmakers begin working with each other next year, said Alan Weil, executive director of the National Academy for State Health Policy, a nonpartisan research organization.

Still, the GOP gains clearly could affect physicians and the health system. Medical liability reform legislation probably will receive a boost from the GOP victories, said Mark A. Peterson, a professor of public policy and political science at the University of California Los Angeles. For example, Alabama Gov.-elect Robert Bentley, MD, and Florida Gov.-elect Rick Scott -- founder of urgent-care chain Solantic -- campaigned on expanding tort reform for physicians and other health professionals. Both were endorsed by their respective state medical associations.

"A central feature of Republican health care policy ... has been the notion that a major driver of costs has been malpractice" lawsuits, Peterson said.

A question of budgets

But lawmakers' relationships with physicians could be tested as states prepare budgets for fiscal 2012, the year Medicaid funding from the 2009 economic stimulus package ends. Many states face budget deficits while Medicaid enrollment is not decreasing, which could pressure state lawmakers to cut spending, possibly including reductions in physician Medicaid pay.

Leaders in some states, including Texas, are discussing the feasibility of opting out of Medicaid to avoid the additional spending eventually required by a federal Medicaid expansion beginning in 2014. Texas' Medicaid agency is expected to finish a report by December on the impact of opting out of Medicaid, requested by the Legislature in 2009, said spokeswoman Stephanie Goodman. Texas has 3.1 million Medicaid enrollees. Republican Arizona state Sen. Russell Pearce, who in January 2011 will become the state Senate president, has said publicly that Arizona should opt out of Medicaid.

The GOP wave could affect health system reform at the state level. At least four new GOP governors -- in Kansas, Oklahoma, Wisconsin and Wyoming -- have said they want to join a 20-state lawsuit to nullify the national health reform law.

Although many state Republicans campaigned against the health reform law, a repeal is not likely overnight -- if at all. Any case against the law is expected to be appealed to the U.S. Supreme Court, and Democrats can block bills in Congress because they control the Senate and White House until at least 2012.

State leaders could influence health reform implementation in smaller ways, according to Richard Cauchi, NCSL health program director. In the 39 states where insurance commissioners are not elected, will governors appoint commissioners who are less likely to challenge health plans' premium increases? Will they use health reform law grants to create consumer health insurance ombudsman offices? And will they create programs to allow external appeals of health plan decisions, or allow the federal government to do so instead?

Other health reform issues are less partisan, Weil said. GOP lawmakers could use tools and dollars given to them through the health reform law -- such as funding for state health insurance exchanges -- to improve access to health insurance and simplify the Medicaid enrollment process.

Weil said even though Virginia Gov. Bob McDonnell staunchly opposes the health reform law, McDonnell appointed Virginia Secretary of Health and Human Resources Bill Hazel, MD, who has been saying that the state must reform its health care delivery system and lower health care costs to remain competitive economically. Dr. Hazel is a former member of the AMA Board of Trustees. Republican Attorney General Ken Cuccinelli already has filed suit against the law, separate from the 20-state case.

"It would be folly to stand by and not use this new tool even if there are parts of the tool that you don't care for," Weil said.

New pro-life conservative lawmakers could enact more anti-abortion legislation, said National Right to Life Director of State Legislation Mary Spaulding Balch. The organization has scheduled a strategy meeting with state legislative leaders on Dec. 7 in Washington.

"We are convinced there are now a significant number of states where we can pass legislation," she said.

Historic GOP gains

The party opposing the president usually gains ground during midterm elections. But the size and locations of GOP victories are surprising, said John Fortier, PhD, a political scientist and research fellow at the American Enterprise Institute, a conservative think tank in Washington, D.C.

"We knew it would be big ... but it was larger than we expected," Fortier said. Republicans now have 54% of, or 3,921, state legislative seats -- the most Republicans have held since 1928, according to preliminary results reported by NCSL. About 6,100 legislative seats were up for grabs in 46 states on Nov. 2.

Republicans had much more enthusiasm than Democrats in this election, said NCSL Senior Fellow Tim Storey, an elections expert. Fifty fewer Democratic candidates ran this year than in 2008, but 800 more Republicans sought state office this year.

Republicans control statehouses they never have before. For example, the GOP now has a 37-30 majority in the Minnesota Senate, its first since partisan state elections began in Minnesota in 1974. Republicans also gained 25 seats in the Minnesota House, giving them a 72-62 advantage in a historically Democratic state. The gubernatorial race is getting a recount because Democrat Mark Dayton won by a margin of less than one percentage point.

Minnesota physicians may be able to work with the new Legislature to repeal a 2% gross revenue tax on physicians, said Minnesota Medical Assn. President Patricia Lindholm, MD.

The tax was adopted to support MinnesotaCare, a health insurance program for people who don't qualify for Medicaid or whose employer pays for less than half the cost of private coverage. But Dr. Lindholm said lawmakers have at times used part of the tax to close budget deficits.

A strong anti-tax stance by the new Minnesota Legislature could come at the expense of the state's public health coverage, especially if there's a Republican governor, Dr. Lindholm said. Many of the new lawmakers probably will support cutting health spending before they would support increasing taxes to pay for health care programs.

Though MMA has not supported the physician tax, "we're very concerned about people getting dropped out of the health care system," Dr. Lindholm said.

New direction on universal coverage

Republicans also achieved historic gains in Maine, a typically more moderate state that has been a leader in expanding health insurance coverage, Peterson said. Republicans took control of the governor's office, Senate and House.

Maine's new crop of conservative leaders could steer the state in a new direction on Dirigo Health, the state's universal health coverage program adopted in 2003. Many of the state candidates were critical of the program, which had a goal of covering the more than 100,000 uninsured Maine residents by 2009. However, enrollment in a key Dirigo insurance plan stands at about 15,000, in part because of high premium costs.

The Maine Medical Assn. will continue to advocate for its policy of universal health care access and coverage, said medical society President Jo Linder, MD. The association's policy also supports the individual health insurance mandate in the health reform law.

"Our strategy may need to change, but in general we will follow our policy and mission statement," Dr. Linder said.

Republicans also gained control of more Southern states, including a sweep of the Alabama Legislature, where they haven't had a majority for 136 years, said Steve Furr, MD, president of the Medical Assn. of the State of Alabama. MASA supported Gov.-elect Dr. Bentley early in the race.

Dr. Bentley, a dermatologist, campaigned on a long list of health care pledges. These include instituting a $250,000 cap on noneconomic damages in medical lawsuits, offering state tax breaks for individuals' spending on health insurance, allowing Alabamans to buy health insurance across state lines and fully funding the state's Medicaid program.

Dr. Furr said Dr. Bentley was not a front-runner early on, but he grabbed a lot of attention by pledging not to accept the $113,000 governor's salary until unemployment declines to 5.2%. About 9% of Alabamans are jobless statewide. "He's going to be a governor without a salary for a couple of years, it looks like," Dr. Furr said.

Dr. Furr isn't sure how much Tea Party activists influenced the Alabama elections. But Alabamans wanted new leaders because of the economy. "If Republicans don't do something, in two years there will be another change," he said.