Written by Rachel Cross

This year, millions of Texans will cast their votes. The results will be an important indicator of the future of health care policy.

Health care is a top priority for American voters, with a recent poll by PwC’s Health Research Institute showing that 71% of American adults in both major parties say that they are likely to vote for a candidate based on his or her health care policies.

But while “Medicare for All” and “public option” proposals continue to dominate the debate stage and news headlines, policy experts believe the most probable election outcome — one where neither party gains control of the executive branch and both chambers of Congress — is unlikely to produce historic changes.

That is not to say, however, that outcomes of the election will not have significant impacts on the national conversation around expanding health care coverage, containing rising drug prices, navigating hospitals’ financial and regulatory landscape, and much more – they will. Regardless of one’s political affiliation, it’s becoming more and more apparent that Texas will play a vital role in shaping the national tone of the 2020 election.

The Race for President: The Medicare for All Debate

During the first three years of President Donald Trump’s administration, overall health care spending increased from $3.4 trillion in 2016 to a projected $3.8 trillion in 2019. The Centers for Medicare & Medicaid Services projects that U.S. health care spending will reach $4 trillion in 2020. However, the increased spend has unfortunately not resulted in a correlating decrease in the number of uninsured Americans. And while the uninsured rate reached a low in 2016 after the passage of the Affordable Care Act, 8.5% of Americans were uninsured in 2018 – an increase from 7.9% in 2017. In Texas, that number is even higher at 17%.

This increase in uninsured Americans has led to a strong response from President Trump’s would-be Democratic challengers. A number of Democratic candidates have voiced support for Medicare for All or of some version of it, including Medicare buy-in and a public option.

Texas hospitals are committed to providing accessible, affordable, high-quality health care, but many express concerns that Medicare for All may not be a viable solution. Instead, hospital leaders across the state have remained committed to building on the progress made over the last decade and warn that a Medicare for All system could cause hospital closures. In April, the New York Times reported that “Some hospitals, especially struggling rural centers, would close virtually overnight, according to policy experts. Others, they say, would try to offset the steep cuts by laying off hundreds of thousands of workers and abandoning lower-paying services like mental health.”

These concerns, along with voter apprehension over costs, potential tax increases and the loss of public insurance resulted in a national poll from Quinnipiac University that found that “Medicare for All has grown increasingly unpopular among all American voters,” with a majority saying it is a “bad idea.” Axios goes on to explain that while Medicare for All is a favorite among Democrats who are disappointed with private insurance, it could become “a real problem for candidates. Not just because of the cost, but because few swing voters want to dump private health insurance.”

In Texas, voters may remain largely split on Medicare for All, but a November poll released by the University of Texas at Tyler indicated that Democratic primary voters’ top choices were former Vice President Joe Biden (28.1%), U.S. Sens. Elizabeth Warren (18.6%), Bernie Sanders (18.4%) and Mayor Pete Buttigieg (8.1%). Overall, the poll showed Texas voters favoring incumbent President Donald Trump for the 2020 presidential election over every Democratic challenger. The poll surveyed 1,093 registered voters in Texas between Nov. 5 and 14 and was conducted in both English and Spanish.

While it remains to be seen who will clinch the Democratic nomination, the voice of Texas voters – and their corresponding 38 Electoral College votes – will carry a lot of weight in November.

U.S. Senate: Sen. John Cornyn’s Turn

Democrats need to gain three seats — and hold their current seats — to control the U.S. Senate in 2021. While much of the national attention has been directed toward the Alabama race, Texas Democrats are seeking to channel the leftover momentum from former U.S. Rep. Beto O’Rourke’s 2018 race against U.S. Sen. Ted Cruz (R-TX) into their 2020 race against U.S. Sen. John Cornyn (R-TX).

But a crowded Democratic primary field has left the majority of Democratic Texas voters undecided on which candidate to vote for.

When it comes to improving access to affordable health care, the Democratic candidates broadly fall in line with the policies proposed by the Democratic presidential candidates. Tzintzún Ramirez supports Medicare for All, Bell supports a Medicare for All option, Hegar supports a Medicare buy-in, and West and Edwards support a public option to the existing ACA. Sen. Cornyn, on the other hand, opposes Medicare for All and continues to voice opposition to the ACA.

Sen. Cornyn’s approval ratings are split between party lines but trend less divisively than those of his colleague Ted Cruz’s in 2018. The November 2019 survey from UT Tyler showed 62.1% of Republicans and 15.9% of Democrats approve of the way he has “handled his job as Senator” with 12.5% of Republicans and 60.4% of Democrats voicing disapproval. 25.4% of Republicans and 32.4% of Democrats responded with “Don’t Know.”

In December, the Democratic Senatorial Campaign Committee endorsed MJ Hegar in hopes of rallying the base around a single candidate. But at the time of this writing, both Politico and 270 to Win still show the race leaning Republican.

U.S. House of Representatives: “Texodus”

In 2019, six Texas Republicans announced they would not run for reelection in 2020 and the “Texodus” has set expectations for a heated campaign cycle. U.S. Reps. Mike Conaway of Midland, Bill Flores of Bryan, Will Hurd of Helotes, Kenny Marchant of Coppell, Pete Olson of Sugar Land and Mac Thornberry of Clarendon released rapid-fire announcements of their upcoming retirements – fueling speculation that Democrats could seize upon the momentum from the 2018 election, pick up some open seats and perhaps defeat three more incumbents in 2020.

Three of the six retiring Texans narrowly won in 2018 and faced a difficult reelection. The seats currently held by Democratic freshmen U.S. Reps. Lizzie Pannill Fletcher of Houston and Colin Allred of Dallas are expected to be competitive races with a slight Democratic advantage. Of the three open seats that Democrats are trying to flip, many believe that Congressional District 23, the seat vacated by Rep. Hurd, is their best chance. The district stretches along the U.S.-Mexico border from San Antonio to El Paso. In 2018, the Democratic candidate, Gina Ortiz Jones, lost by less than 1,000 votes. In 2020, she is viewed as the swing district’s likely nominee.

But with murmurings of an impending “blue wave,” it is still worth noting that President Trump won Texas by nine percentage points in 2016 and, in the 2018 midterms, 23 of Texas’ 36 congressional districts voted for Republicans. While it’s clear that the state is becoming more and more competitive, it may be an overstep to assume the parties have reached an equilibrium in less than two years.

When it comes to health care policy, Texas voters continue to be split amongst party lines. In a 2019 University of Texas/Texas Tribune poll, 45% of Texas voters stated they preferred the current system, 44% preferred a universal system and 10% indicated that they did not know or had no opinion. Those differences widely varied based upon party identification.

Texas is home to the largest uninsured population in the country and, as such, one can expect the U.S. House races to mirror their national counterparts in a lively discourse about the future of health care policy and the Congress’ role in reform.

State Races in the General Election Spotlight

Elections in Texas are typically decided in the primary. But this year’s Nov. 3 general election will prove to be more crowded and competitive than in recent years.

Democrats in the Texas House of Representatives only need to secure nine additional seats to take the majority and gain control of the lower chamber for the first time since 2001. There are 10 Texas House districts, previously held by Republicans, where the Optimal Republican Voting Strength—or the percentage of the vote a Republican candidate could get in the 2020 general—is between 47%-54%. Conversely, there are about 16 House districts, previously held by Democrats, where 45%-51% of voters are expected to vote with the GOP, according to Baselice & Associates’ 2020 projections.

The party that controls the House will have the upper hand in selecting the new House Speaker, a coveted seat vacated by first-term Speaker Dennis Bonnen (R-Angleton) after a stunning fall from grace this summer. The new Speaker—who will set the House priorities, control the flow of House legislation and select chairs for the chambers’ committees—will have the latitude to change the way the House conducts its business significantly.

On the Senate side, four Democrats are vying for the chance to unseat incumbent State Sen. Pete Flores (R-San Antonio) from a district with 45% ORVS. Politicos will keep a close eye on this race as a Democratic victor in the general would eliminate the supermajority that allows Senate Republicans to bring a bill to the floor without Democratic support.

Whether the race for the Texas House is the preeminent state contest of 2020 remains to be seen. What we do know is that the results of the state’s general election will be an important indicator of the policies the Texas Legislature considers during the next legislative session in 2021.

Get Out the Vote

The March 3 primary will be an important election for Texas hospitals. Voters in the Texas primary will choose who will appear on the general election ballot. The lawmakers who will make the laws in Texas and Washington, D.C. that affect Texas hospitals and communities depend on your vote.

Texans who are registered to vote by the Feb. 3 deadline can take advantage of early voting from Feb. 18 - 28 or plan to visit the polls on Election Day. Visit VoteTexas.gov to find out who is on the ballot and find your polling place.

On March 3 and Nov. 3, millions of Texans will cast their votes and make their voices heard. Will you be one of them?

Learn more about voter registration and the upcoming Texas election here: https://www.votetexas.gov