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A presidential election year means there’s not much hope for big health fixes from the federal government. That doesn’t mean states won’t try.

Health care has dominated the Democratic presidential primary and is consistently ranked as one of voters’ top concerns in public opinion polling. It’s not hard to see why: The cost of everything has gone up, from premiums to deductibles to prescription drugs, and the number of uninsured people in the U.S. is rising once again.

The federal government has plenty of proposals to tackle these problems, but no major fixes were signed into law this year. And as we enter a presidential election with a divided House and Senate, hopes are not high for anything passing next year, either.

Of course, that doesn’t mean the issues go away. In the absence of federal action, state governments are working to help lower costs and expand insurance coverage. Below, we look at what could happen in health policy next year in presidential battleground states. Taken together, they capture the array of serious health issues facing America today.

NORTH CAROLINA: Medicaid on the ballot

When the Supreme Court in 2012 ruled that states could refuse the Affordable Care Act’s requirement to expand Medicaid to low-income adults, it wasn’t clear if any red states would ever sign up. But over the past seven years, the promise of more federal funding to provide insurance for the state’s poorest residents has proven hard to resist, even for states that have heavily-Republican legislatures, like Arizona and Louisiana. Still, most states in the South have refused to expand the program, including North Carolina. 

But Democratic Gov. Roy Cooper is up for re-election in the state in 2020, and he plans to make the fight to expand Medicaid a “key feature” of his campaign, according to the Washington Post. This strategy doesn’t come out of nowhere—Virginia expanded Medicaid in 2019 over most Republicans’ objections, and handily took over the state legislature in the subsequent election. Louisiana and Kentucky’s Democratic governors also campaigned on keeping their state’s Medicaid expansion programs and won in their right-leaning states. 

If this effort can prove successful in North Carolina, the Kaiser Family Foundation estimates 400,000 people in the state would finally get health insurance.

WISCONSIN: Recommending ways to cut drug costs

Perhaps the health issue that came to the forefront most in 2019 was the rising cost of prescription drugs and patients’ inability to pay for them. Nearly 80% of Americans said the cost of prescription drugs is “unreasonable” in a Kaiser Family Foundation poll. Democrats in the House passed a bill that would allow Medicare, the federal government’s insurance for Americans age 65 and up, to negotiate the cost of drugs, something they are currently prohibited from doing. And even President Trump has called for importing drugs from outside the U.S., which are sold at a fraction of the price. 

But in the absence of federal action, states have taken matters into their own hands. Colorado, for example, has laws capping the price of insulin and allowing the importation of drugs from Canada. Wisconsin, like most states, is just starting down this path. The state legislature had three bills referred to committees this year, also capping the price of insulin, among other things. But none of those bills became law, so Democratic Gov. Tony Evers formed a task force to analyze data on prescription drugs in the state and ultimately recommend actions they can take to reduce drug prices. The task force, which met for the first time in November, will issue a report by the end of 2020 with its recommendations.

PENNSYLVANIA: Eradicating surprise bills 

A flurry of end-of-year legislating had health policy watchers thinking they were about to witness a miracle: a bipartisan effort from Congress to ban what has become known as “surprise billing.” That is when you get a bill for treatment that is not covered by your insurance, even if you’re at a hospital that is in your insurer’s network. 

The effort fell through at the last minute, but states like Pennsylvania are trying to pick up the slack, again in a bipartisan fashion. Republican state Rep. Tina Pickett and Democratic state Rep. Tony DeLuca introduced their own bill, which would set “baseline pricing” for out-of-network bills. Several states have taken similar steps to prevent surprise billing, and the Pennsylvania legislation made it out of committee with unanimous support. According to the Philadelphia Inquirer, it’s unclear when and if it will get a full vote, and state legislators may prefer to wait on Congress to take federal action. But expect the issue to return.

VIRGINIA: Pausing Medicaid “work requirements”

Virginia Democrats made history in November, fully taking control of the state legislature for the first time in decades. That reset is trickling down to health care in the state, which expanded Medicaid at the start of 2019. Democrats pushed for years to expand Medicaid, but without a majority they needed a handful of Republicans to sign on. The deal they struck set up a process to establish “work requirements” for Medicaid recipients, mandating that they prove to the state government that they are working or looking for a job. 

But Democrats’ resounding victory moved Gov. Ralph Northam to announce just a few weeks after the election that he was “pausing” the process to establish those rules. He had some firm ground to stand on: Federal judges have stopped work requirements in Kentucky, Arkansas and New Hampshire, and Indiana and Arizona have paused their own efforts due to the legal challenges.