Andrea Deutsch stands in her pet store in Narberth, Pa. Deutsch is one of the millions of people who receive federal aid to help them pay their health insurance premiums on an Affordable Care Act exchange. The extra help is set to expire at the end of 2025, and states say they don’t have the money to replace it. (Courtesy of Andrea Deutsch)

Andrea Deutsch, the mayor of Narberth, Pennsylvania, and the owner of a pet store in town, doesn’t get health care coverage through either of her jobs. Instead, she is enrolled in a plan she purchased on Pennie, Pennsylvania’s health insurance exchange.

Deutsch, who has been mayor since 2018, is paid $1 per year for the job. Her annual income, from Spot’s – The Place for Paws and her investments, is about $50,000. The 57-year-old, who is diabetic, pays $638.38 per month for health care coverage — about half of the $1,272.38 she’d owe without the enhanced federal subsidies Congress and the Biden administration put in place in 2021.

But that extra help is set to expire at the end of 2025. It would cost an estimated $335 billion over the next decade to extend it — a step the Republican-controlled Congress and the Trump administration are unlikely to take as they seek budget savings to offset potential tax cuts.

States say they don’t have the money to replace the federal aid. In Pennsylvania, for example, doing so would take about $500 million per year, according to Devon Trolley, the executive director of the state’s exchange.

“That is a significant amount of money, an insurmountable amount of money,” Trolley said.

The disappearance of the federal help would make coverage unaffordable for millions of Americans, including Deutsch. She said it would be a struggle to pay double what she is paying now.

“You try not to go bankrupt by the end of your life,” Deutsch told Stateline. “You need assets to take care of yourself as you get older and to have a little bit of security.”

Enhanced subsidies

The 2010 Affordable Care Act included some subsidies to help people purchase health insurance on the exchanges created under that law. Under the enhanced subsidies that started in 2021, some people with lower incomes who qualified for the original subsidies have been getting bigger ones. And those with higher incomes, who wouldn’t have been eligible for any help under the original rules, are now receiving assistance.

Thanks to the enhanced subsidies, people making up to 150% of the federal poverty level, or $22,590 for an individual, are now getting free or nearly free coverage. And households earning more than four times the federal poverty level, who didn’t qualify for subsidies before, are getting some help.

The enhanced aid also has helped push ACA marketplace enrollment to record levels, reaching more than 21 million this year. Southern states that have not expanded Medicaid as allowed under the ACA have seen the most dramatic growth in marketplace enrollment since 2020, according to KFF, a health policy research organization. The top five states with the fastest growth are Texas (212%), Mississippi (190%), Georgia (181%), Tennessee (177%) and South Carolina (167%).

If the enhanced subsidies go away, premium payments will increase by an average of more than 75%, according to KFF. Some people, like Deutsch, would see their payments double.

Given those premium hikes, millions of Americans would no longer be able to afford the coverage they’re getting on the exchanges, according to the nonpartisan Congressional Budget Office. CBO estimates that enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 to 15.4 million in 2030. Some of those people would find coverage elsewhere, but others would not.

Edmund Haislmaier, a senior research fellow at the conservative Heritage Foundation, said Republicans view the expiration of the enhanced subsidies as “an opportunity to rework and address some of the basic flaws in the ACA.”

Before the ACA, Haislmaier said, many self-employed people, such as small-business owners and freelancers, were able to find their own private insurance at competitive prices. But the health care law destroyed that market, he said, leaving such people with a selection of expensive and subpar plans.

Haislmaier said it would take time for the Trump administration to determine how it wants to change the ACA — which President-elect Donald Trump unsuccessfully tried to repeal during his first term — but that “you can do that in a way that preserves access and preserves subsidies for the lower-income people who were the primary focus of the ACA.”

States’ limitations

But Jared Ortaliza, a research associate at KFF, said letting the enhanced subsidies expire could result in higher premiums for everyone. That’s because higher prices likely would prompt many healthier people to forgo insurance, he said. Their departure would leave only chronically ill people on the exchanges, and the cost of their care is higher.

“If sicker enrollees need coverage because they need care, they’ll still choose to buy it, potentially. And if the market were sicker as a whole, that could drive premiums upward as well,” Ortaliza told Stateline.

Ortaliza said states might consider keeping premiums down through so-called reinsurance, or reimbursing insurers for their most expensive enrollees. Theoretically, they also could try to replace the expiring federal aid with their own money.

But few if any states have the financial flexibility to do that, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy.

“There might be a couple states who don’t have current state subsidies that might add that, but that will be very nominal,” Tewarson told Stateline, adding that officials from different states have been discussing potential solutions. “They are all assuming that they would just have to absorb the loss of coverage across the population.”

Trolley, the head of the Pennsylvania exchange, said her state is working to provide its own subsidy to make the marketplace plans even more affordable. But even when fully implemented, it would spend only $50 million on that help, a tenth of what it would need to replace the federal aid.

Two-thirds of the 435,000 Pennsylvanians who purchase insurance on the marketplace joined after the enhanced federal subsidies were put in place in 2021. If they expire, Trolley said, she worries that 100,000 or more exchange participants will leave.

Jessica Altman, executive director of California’s exchange, said her state is in a similar situation. California currently receives $1.7 billion annually in enhanced subsidies from the federal government and spends an additional $165 million of its own money to keep costs down.

California estimates that if the subsidies expire, monthly premiums for the state’s enrollees would increase by an average of 63%. More than 150,000 people would no longer be eligible for federal help, and between 138,000 and 183,000 would disenroll, the state estimates.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

Workers sort peaches at a packing house after they were harvested from the trees of a Georgia farm in July 2023. Georgia has work requirements under its partial expansion of Medicaid, but its program has fallen far short of enrollment projections and has cost more than $26 million. (Joe Raedle/Getty Images)

Trevor Hawkins, an attorney at Legal Aid of Arkansas, remembers how busy his job got when the state for a time imposed work requirements on Medicaid recipients: His office was swamped with frantic phone calls from people who said they couldn’t comply with the new rule because they weren’t healthy enough to work or had to care for sick relatives.

“A whole heap of folks, after a month or two, started getting notices saying, ‘Hey, you’re out of compliance, and you’re going to lose your coverage,’” Hawkins told Stateline. For many people, he said, keeping their coverage was “absolutely vital to maintaining their health or getting better so they might work again.”

In June 2018, Arkansas became the first state to require some Medicaid recipients to work, volunteer, go to school or participate in job training to receive benefits. By the time a federal judge halted the policy in April 2019, 18,000 adults had lost coverage.

Arkansas was one of 13 states that received permission to impose work rules on at least some Medicaid recipients during the last Trump administration. Nine additional states requested permission to enact Medicaid work requirements during Trump’s term but had not won approval by the time it ended.

When the Biden administration came into office, it rescinded all the approvals. But now that Trump is coming back, many of those states will try again — and they’ll have a supportive U.S. Congress in their corner.

Republicans on Capitol Hill are eager to find ways to pay for extending tax cuts enacted during Trump’s first term in office, and Medicaid — funded jointly by the federal government and the states — is in their sights. Requiring states to establish Medicaid work rules, as many Republicans would like to do, would cut federal spending by an estimated $109 billion over a decade, according to the Congressional Budget Office. That’s because the cost for about 900,000 people would shift entirely to states, while another 600,000 people would become uninsured, CBO estimated. About 72.4 million people are enrolled in Medicaid.

Arkansas renewed its efforts even before Trump’s victory. Last year, Republican Gov. Sarah Huckabee Sanders requested federal approval from the Biden administration to apply work rules to able-bodied adults who are covered through the state’s expansion of Medicaid under the Affordable Care Act, and who are enrolled in health plans that Arkansas Medicaid purchases for them on the state’s health insurance exchange. That application is pending.

Georgia, after prevailing in a legal fight with the Biden administration, already has work requirements in place for people covered by its partial expansion of Medicaid. And Idaho, Mississippi, Oklahoma, South Dakota and Tennessee have pending requests to require at least some of their Medicaid recipients to work.

Meeting requirements

Supporters say requiring Medicaid recipients to work, study or train for a career gives them a boost toward self-sufficiency and financial stability. Kristi Putnam, the secretary of the Arkansas Department of Human Services, said in a statement announcing her state’s latest request that it would challenge people to “embrace economic opportunities that can lead to true job advancement.”

“Meaningful work connects people to purpose — and through the pandemic we have seen negative mental health impacts from people feeling disconnected,” Putnam said.

Critics, however, say such rules end up hurting far more people than they help. In a 2020 study examining how the Arkansas work requirements played out, researchers from the Harvard T.H. Chan School of Public Health “found no evidence that the policy succeeded in its stated goal of promoting work and instead found substantial evidence of harm to health care coverage and access.”

More than 95% of the Arkansas beneficiaries the researchers surveyed already met the work requirement or should have qualified for an exemption. The main reason people lost coverage, the researchers found, was because they had trouble verifying that they were complying with the rules. Many of those who lost their coverage stopped taking their medications, delayed care and fell into medical debt.

“Our results should provide a strong note of caution for federal and state policy makers considering work requirement policies in the future,” the researchers concluded.

Under the rules Arkansas put in place during the first Trump administration, Medicaid participants under age 50 had to report that they spent at least 80 hours each month working, attending school, in job training or volunteering. The rule only applied to people who became eligible after Arkansas expanded Medicaid under the ACA to cover adults making up to 138% of the federal poverty level. And people were exempt if they were pregnant, had a child under 18 at home, were disabled, had to care for a person unable to care for him or herself, were in alcohol or drug treatment, or were in school or job training full time.

About 70,000 of the roughly 270,000 Arkansans on Medicaid were subject to the new rules, and about 1 in 4 of those lost coverage.

Unlike Arkansas, Georgia has not expanded Medicaid under the Affordable Care Act. But its Pathways to Coverage program, launched in July 2023, allows people with household incomes up to 100% of the federal poverty level who aren’t already eligible for Medicaid to enroll in the program if they fulfill work requirements. Georgia’s qualifying activities and exemptions are similar to the ones Arkansas had.

Fiona Roberts, a spokesperson for the Georgia Department of Community Health, told Stateline that as of Nov. 15, there were 5,548 people enrolled in the program and that a total of 7,518 people had been enrolled at some point — evidence, she said, that the program is helping people move from Medicaid to private insurance.

But in its first year, Pathways to Coverage only enrolled about 4,200 people — many fewer than the 25,000 the state had predicted. The cost of the program as of the end of 2023 was $26.6 million, and more than 90% of that went toward administrative and consulting costs, according to KFF, a nonprofit health research group. If Georgia had opted for a full expansion under the ACA, the federal government would have picked up 90% of the tab and the state would have covered about 359,000 people.

Leah Chan, director of health justice at the Georgia Budget and Policy Institute, said work requirements are particularly challenging for people living in rural areas.

“If you don’t have broadband internet at your house, you’re not going to be able to upload the documentation and your pay stubs,” Chan told Stateline. “Even eligible people can’t keep up with it, particularly in rural areas where there are additional barriers to participation.”

‘Learning from mistakes’

Benjamin Sommers, a professor of health care economics at the Harvard T.H. Chan School of Public Health and one of the authors of the Arkansas study, said the experience with work requirements there and in Georgia should give other states pause.

“All that ended up happening was people lost coverage due to red tape, became uninsured, and in some cases, we saw that they had worse access to health care,” Sommers said.

But Arkansas Republican state Rep. Aaron Pilkington, who serves on the health committee in his chamber, said Medicaid work rules are “100% on the table and something we’ll look to ask for from the Trump administration.”

“They can find work and get better health insurance through their employer,” said Pilkington. He said the volunteering and education options make the rules even more attractive.

Meanwhile, in some of the 10 states that have not expanded Medicaid under the ACA, the inclusion of work requirements might be the only way politically to get expansion over the finish line.

“Most of the Democrats I’ve spoken to did not want the work requirements, but to get it passed through the Mississippi legislature it’s most likely going to have one,” Mississippi Republican state Rep. Sam Creekmore told Stateline.

“We’ve looked at Georgia’s plan. We recognize the pitfalls and are hopefully learning from mistakes.”

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Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and X.

President-elect Donald Trump on Tuesday announced his intent to nominate Dr. Mehmet Oz as administrator of the Centers for Medicare and Medicaid Services. In this photo, Oz speaks at a March 15, 2022 press conference in Harrisburg, Pennsylvania. (Photo by Pennsylvania Capital-Star).

South Dakota Sen. John Thune speaks to reporters after being elected Republican leader during a closed-door, secret ballot election held inside the old Senate chamber in the U.S. Capitol building on Wednesday, Nov. 13, 2024. At right is Sen. Shelley Moore Capito, a West Virginia Republican elected as the Republican Policy Committee chair. (Photo by Jennifer Shutt/States Newsroom) 

WASHINGTON — Republicans in the Nov. 5 election took over the White House, the U.S. Senate and as of late Wednesday, the House, after calls were made in enough races to project a majority.

They are expressing high hopes for unified control of government. But before they’ll be able to celebrate enacting sweeping changes to the country’s tax code or overhauling the health insurance marketplace, they’ll need to broker agreement between centrist lawmakers and far-right members in Congress.

More often than not, those two factions of the GOP hold significantly different ideas about how to draft legislation and strong opinions about whether to amend it on the floor.

Keeping everyone on the same page will be crucial for Republican leaders once the new Congress begins Jan. 3, especially since they have just three votes to spare in the Senate and a razor-thin majority in the House.

States Newsroom looked at what’s ahead for Republicans as they begin sorting through where to make changes to U.S. law in seven key policy areas:

TAXES

Nearly every Republican politician campaigned on addressing the country’s tax structure, making it one of the first issues the party is expected to take up when the next session of Congress begins.

The GOP will likely use the complicated budget reconciliation process to address the tax code, the same way lawmakers did in 2017 when they passed their signature tax law during President-elect Donald Trump’s first term in office.

That reconciliation process would allow Republicans to avoid the Senate’s 60-vote legislative filibuster that would otherwise require them to get Democratic support. But the process has strict rules and requires a marathon amendment voting session in the Senate that’s often called a vote-a-rama.

Some provisions in Republicans’ original tax law have already expired or will do so in the coming months, giving the GOP incentives to jump through the many hoops that come with the reconciliation process.

Extending the expiring provisions will bring along a hefty price tag, however.

The nonpartisan Committee for a Responsible Federal Budget wrote in an analysis released in late September that extending the individual and estate tax elements in the law would increase the deficit by $3.9 trillion through 2035. Republicans opting to extend or bring back tax code changes for business would likely increase the deficit to $4.8 trillion.

Maya MacGuineas, president of the Committee for a Responsible Federal Budget, expressed concerns at the time about lawmakers ignoring or diminishing the deficit impact. 

“There will undoubtedly be efforts to pretend that extending the tax cuts is free – obviously this is not the case,” she said. “Extending policies that are scheduled to expire — and were scored as expiring — would clearly add to the national debt.”

MacGuineas added that lawmakers “should consider carefully which parts of the TCJA are working, which parts aren’t, and if they want to extend some parts, how to responsibly extend them without increasing the debt beyond current law.”

IMMIGRATION

Republicans are expected to hold votes on legislation addressing border security and immigration after much of their campaign for Congress focused on those two areas.

Whether they’ll be able to do that through the reconciliation process with only GOP support or through the traditional legislative process, which requires bipartisanship in the Senate, will depend on how exactly they write the bill and what budget impacts the various provisions will have.

Immigration and border security legislation would fail to comply with a reconciliation rule in the Senate, also known as the Byrd Rule, if it produces a change in federal revenues or spending that is deemed “merely incidental” by the Senate parliamentarian.

While the requirement is vague, it could apply to several items that don’t have big price tags when considered as part of the multi-trillion-dollar federal budget.

For example, Democrats’ efforts to raise the federal minimum wage as part of the reconciliation process in 2021 were deemed “merely incidental” by the Senate parliamentarian and removed from the bill.

Trump has already laid out his wish list for an immigration-related bill he wants Congress to send to his desk.

Trump reposted campaign videos on social media in early September requesting Congress pass legislation to prevent future presidents from using executive authority to grant humanitarian parole — something the Biden administration has used to allow more than 1 million people to obtain work permits and live in the United States temporarily. 

Trump has called the use of parole authority “abuse,” but it’s been used by presidents since 1956, during the Eisenhower administration.

Trump, who campaigned on mass deportations of immigrants without proper legal status, is also expected to ask Congress to foot the bill for his promise to deport more than 13 million people.

Getting any immigration-related policy to the president-elect’s desk will be daunting since it’s been almost four decades since Congress overhauled U.S. immigration law.

“The last big immigration bill was passed in 1986 when Ronald Reagan was president and both houses of Congress were held by Democrats,” according to an analysis from the nonpartisan Brookings Institution. “A smaller bill was passed in 1990 when George H.W. Bush was president and both houses of Congress were still controlled by Democrats.”

Earlier this year, a bipartisan border security and immigration bill was brokered by Connecticut Democratic Sen. Chris Murphy, Oklahoma Republican Sen. James Lankford and Arizona independent Sen. Kyrsten Sinema.

The trio of senators spent months negotiating the particulars of the deal only to have it scuttled after Trump told GOP members he didn’t want the legislation to pass.

That legislation could be used as a starting point if Republicans are unable to move an immigration bill through the reconciliation process and want to get a bill past the Senate’s 60-vote legislative filibuster.

TARIFFS

Tariffs could become one point of contention between Republicans in Congress and the Trump administration.

The president-elect has vowed to stack tariffs of at least 10% on nearly all goods entering the country, raising alarm bells with economists and free-trade Republicans about the impact that would have on consumer prices.

Trump said in mid-October at the Economic Club of Chicago that he hoped to implement tariffs on foreign-made products as high as 100% or 200%.

“The higher the tariff, the more likely it is that the company will come into the United States, and build a factory in the United States so it doesn’t have to pay the tariff,” Trump said, rejecting the premise that high tariffs could harm Americans.

Mary Lovely, senior fellow at the Peterson Institute for International Economics, told States Newsroom in an October interview that imposing tariffs could risk “starting a trade war with the entire world.”

Lovely’s research with economist Kimberly Clausing, also of PIIE, found that Trump’s threats to slap tariffs as high as 20% on all foreign products, combined with his threats of 60% tariffs on all Chinese goods, could cost the typical American household over $2,600 annually.

HEALTH CARE

House Speaker Mike Johnson, R-La., said repeatedly during the final weeks of the campaign that he wants to overhaul the 2010 health care law that most people refer to as the Affordable Care Act, or Obamacare.

He hasn’t shared details about what aspects of that law he wants to end or change, but said during a late October interview on Fox Business that he wants to address health outcomes.

“I said the ACA, unfortunately, is deeply ingrained in our health care system now,” Johnson said. “Do we need further improvements? Absolutely. We need to expand quality of care, access to care and obviously lower the cost of health care.”

Republicans used the budget reconciliation process to try to repeal and replace the ACA in 2017, but were unsuccessful, largely due to the late Arizona Sen. John McCain rejecting the bill.

Even with the budget reconciliation process to get Republicans around the Senate’s 60-vote legislative filibuster, it will be extremely difficult for leaders to get the party unified on any health care bill of that magnitude.

Republicans using the budget reconciliation process for tax policy and health care would take up two of the three opportunities they’ll have to adopt budget resolutions with reconciliation instructions during the 119th Congress.

GOP leaders could try for a round three, though once all is said and done with the first two reconciliation bills, Republicans might need to shift their attention toward the 2026 midterm campaigns.

VOTING

Republican lawmakers have argued legislation is needed to bar noncitizens from voting in federal elections, even though it is already illegal and rarely happens. The party is expected to try again next Congress, once it holds a majority in both chambers of Congress. 

The GOP House passed a bill this summer that would have required proof of citizenship to register to vote, but the Democratic-controlled Senate never acted on it.

Trump wrote on social media that he would demand that voter ID laws and proof of citizenship be required for voting, something that Congress would have to pass, although it’s unclear if such legislation could overcome the 60-vote threshold in the Senate.

The issue is important to Trump, as Johnson traveled to the president-elect’s residence in Palm Beach, Florida, to unveil the House’s intention to pursue the issue.

SPENDING

Republicans campaigned this year on cutting government spending, but have rarely done so when they held the majority in both chambers of Congress.

The challenge lies in how government spending is approved and how much the various departments and agencies require to function.

During fiscal 2023, the federal government spent $6.1 trillion, with $3.4 trillion going to mandatory programs, like Social Security, Medicare and Medicaid. Those programs run on autopilot, so lawmakers don’t need to negotiate the particulars every year the way they do other programs.

An additional $1.7 trillion was spent on so-called discretionary programs, which are funded through Congress’ annual appropriations process. That funding went to programs categorized as either nondefense, which received $917 billion, or defense, which got $805 billion.

The nondefense funding goes to several departments, including Agriculture, Energy, Health and Human Services, Homeland Security, Interior, Justice, State and Transportation. Smaller agencies, like NASA and the National Science Foundation, are also funded through nondefense accounts.

Republicans have proposed cuts in the past, but members of the party who understand the federal ledger often explain that if members really want to address the government spending more than it takes in, they’ll have to address Medicare, Medicaid and Social Security.

The math, otherwise, won’t work.

Republicans could make tweaks when they write their reconciliation bills, though they’ll need those to comply with the Byrd Rule and not have a “merely incidental” impact on the federal ledger. 

EDUCATION

Having secured unified GOP control of government, Trump’s sweeping vision to “save American education” could set the stage for significant changes in U.S. education policy.

The president-elect has vowed to eliminate the U.S. Department of Education and said he wants to move education “back to the states.” States and local governments bear much of the responsibility for funding K-12 schools, but the Department of Education handles Pell Grants for college students who demonstrate financial need and enforces civil rights cases, among other things.

Congress going along with plans to eliminate the department could have profound impacts on the billions of dollars in funding the agency provides for low-income K-12 schools, special education and federal student aid.

Trump also vowed to roll back updated Title IX regulations on his first day back in office.

President Joe Biden unveiled the final rule for Title IX in April, which strengthens federal protections for LGBTQ+ students and “protects against discrimination based on sex stereotypes, sexual orientation, gender identity, and sex characteristics,” according to the Education Department.

GOP members on the House Committee on Education and the Workforce have criticized the new Title IX rules and are likely to fall in step with Trump’s wishes to roll back the regulations.

Trump has also criticized the Biden administration’s student loan forgiveness efforts, dubbing them “not even legal.” He could discontinue the Biden administration’s new student loan repayment plan known as Saving on a Valuable Education, or SAVE. The plan is currently on pause due to legal challenges from Republican-led states.

Last year, Senate Republicans tried to strike down the rule.

Like Trump, Republicans have focused on “parental rights” in education. House Republicans passed their own bill on the issue last year.

Republicans are likely to continue scrutinizing higher education institutions from diversity initiatives to college students protesting the war in Gaza.

A GOP measure that would bar accrediting organizations from requiring colleges and universities to adopt diversity, equity and inclusion policies as a condition of accreditation passed the House in September.

Shauneen Miranda and Ashley Murray contributed to this report.  

Sen. Tammy Baldwin and Eric Hovde in the 2024 Senate campaign debate | Screenshot via Youtube

This year’s race to represent Wisconsin in the U.S. Senate presents  a stark contrast between incumbent U.S. Sen. Tammy Baldwin and challenger Eric Hovde.

Baldwin, a  two-term senator who previously served in Congress for more than a decade and in state and local office before that, faces Hovde, a banker whose only political experience was a failed Republican primary run for the same seat 12 years ago.

Baldwin points to the results of her lifelong work in politics — successful legislation addressing health care coverage, veterans, manufacturing and human rights, and also ambitious measures that have not passed yet.

Hovde is dismissive of Baldwin’s record and depicts his business background as an asset he can use in Washington to benefit Wisconsin. Combative during their only debate on Friday, Oct. 18, as well as in public interviews, he has  taken a leaf from the playbook of former President Donald Trump, both in style and in the subject matter that he highlights.

Whether control of the Senate remains with the Democrats or shifts to the Republicans could turn on the outcome of the Wisconsin race, one of a handful getting close scrutiny in this election.

Negative campaigning has been commonplace for decades, but it’s especially prominent in the Baldwin-Hovde race.

“There’s a lot of mud being slung,” says Lilly Goren, political science professor at Carroll University in Waukesha. “It’s not as if we haven’t had mudslinging in Wisconsin politics before, but it feels like there’s a little bit more going on.”

Heavy attacks

From the moment Hovde entered  the race, Democrats have pounced on the bank owner’s California connections, starting with his Orange County mansion and his high profile in the Southern California community, where a local publication named him among the county’s “most influential people.” In press releases, the Democratic Party of Wisconsin has taken to calling him Eric Hovde (R-Laguna Beach).

Hovde defends himself as a Wisconsin native and still a legal resident who  maintains his voting registration in Madison. At the debate he pulled out a utility bill to prove he has a local address.

Democrats have pushed for Hovde to declare that if elected he would remove himself from SunWest bank, which operates in California but moved its headquarters a few years ago to Utah. In September, the Wisconsin State Journal reported that Hovde said he would “step away” from the bank and was considering whether to put his assets in a blind trust if he goes to Washington.

Hovde, meanwhile, has pushed back with accusations that Baldwin’s partner, Maria Brisbane, an investment and wealth management adviser, puts the senator in a conflict of interest in connection with Baldwin’s Senate oversight roles.

The Senate’s ethics rules don’t address such a relationship, however. When Hovde raised the matter during the debate, Baldwin retorted that “Eric Hovde should stay out of my personal life, and I think I speak for most Wisconsin women that he should stay out of all of our personal lives.”

Reproductive rights

That response alluded to an issue that Baldwin has highlighted repeatedly: abortion and reproductive rights. During a rally with vote canvassers earlier in October, Baldwin recalled that Hovde “celebrated when the Dobbs decision came down” in June 2022 overturning the nationwide right to abortion enshrined in the U.S. Supreme Court’s Roe v. Wade decision a half-century ago.

Referring to positions Hovde took in his 2012 GOP primary campaign, she added, “Previously he said he was 100% against abortion, and we have to take him at his word.”

Hovde has endorsed the Dobbs decision outcome for leaving the legality of abortion up to individual states. But he has also appeared to soften somewhat his earlier statements of opposition, saying several times, including in last week’s debate, that “women should have a right to decide early on in their pregnancy,” but not defining what period of time that would involve. 

Under Roe, abortion could not be regulated by the state during the first trimester. Later in pregnancy, abortion restrictions were permitted.

During the debate, Hovde accused Baldwin of supporting abortion  late in pregnancy, “where a baby can be born healthy and alive,” calling such abortions “unconscionable.” Baldwin quickly shot back, “Eric Hovde, that does not happen in America and it’s very clear that he has never read Roe v. Wade.”

Baldwin has authored legislation to codify the Roe decision. “I’m pushing to have that be the law of the land. Your rights and freedom should not depend on your ZIP code or the state in which you live,” she said.

Notwithstanding the wide range of other subjects that have surfaced in the race, Goren, the Carroll University professor, said in an interview that she’ll be watching how abortion and reproductive rights in the post-Dobbs era continue to play out at the ballot box.

“This is an issue area that both campaigns are focusing on in different ways,” she said. Wisconsin’s 1849 feticide ban — interpreted as an abortion ban for the first year and a half after Roe was rolled back until a Dane County circuit judge ruled that it did not apply to elective abortions — has given the topic new urgency  for many women in the state.

Farm bill clash

When asked whether he would support passing the 2023 farm bill during the debate, Hovde answered, “Well, I’m not an expert on the farm bill because I’m not in the U.S. Senate at this point.” Then he launched  into a call for farm bills “to get back to farmers” and to address the “regulations that Senator Baldwin and her allies continue to push on them.”

Milwaukee Journal Sentinel columnist Dan Bice called Hovde’s answer “the worst moment” of the debate.

For Baldwin, it offered a target that allowed her to promote her recent endorsement by the Wisconsin Farm Bureau — the GOP-leaning group’s first endorsement of a Democrat in nearly two decades.

Wisconsin farmers have told her “they’re very eager to have Congress pass a new farm bill,” she said. The hold-up, she added, was that the Republican-controlled U.S. House has “basically eviscerated nutrition programs. Farmers support nutrition programs because it means purchasing their goods.”

Citing one of Hovde’s key talking points — calling for a cutback in federal spending to 2019 levels — she added that it would “cut the U.S. Department of Agriculture by 30% — that is not standing up for our farmers.”

Incumbent’s resume

Challengers typically deploy “career politician” as an epithet, but for Baldwin the term is both accurate and a point of pride. She readily traces some of her key legislative victories through that history.

Earlier this year, marking the passage in 2022 of the PACT Act, giving veterans exposed to toxic chemicals in conflicts  going back to the Vietnam War greater access to federal benefits, Baldwin recalled her introduction to the issue through a staffer when she was still in the U.S. House.

Likewise, she frequently points to the key role she played in shaping the  Affordable Care Act (ACA).

“It was my provision that allowed young people to stay on their parents’ health insurance till they turned 26,” Baldwin said during the  debate, repeating a campaign talking point.

Among her most recent trophies is language in the 2022 Inflation Reduction Act that for the first time empowers Medicare to negotiate the price of prescription drugs. The act also imposes caps on the out-of-pocket expenses Medicare recipients must bear and limits their cost of insulin to $35.

“We need to build upon the Affordable Care Act, and we need to build upon our efforts to negotiate lower prescription drug prices,” Baldwin said during Friday’s debate.

While health care has been among her top concerns, she also directs attention to other parts of her lawmaker’s resume.

Economy and rebuilding U.S. industry

When President Joe Biden’s administration and allies in Congress drew up the CHIPS and Science Act to support the return of technical manufacturing from overseas to the U.S., particularly in the computer chips that gave the legislation its nickname, Baldwin turned to a 2019 Brookings Institution industrial policy report.

Drawing on that document she pitched the inclusion of a “technology hub” program that would direct federal funds to support the development of specialized advanced domestic production projects.

After the bill was enacted, the Wisconsin Economic Development Corp. worked with Bio-Forward, a consortium of industries and institutions in the state, to propose a tech hub focused on the emerging science of tailoring medical diagnosis and treatment to the individual genetic profiles of patients. Baldwin championed the Wisconsin entry for a competitive tech hub grant, then joined an event in August to show off one of the participating businesses.

Those and other major initiatives that emerged from Congress and the White House in the first two years of the Biden administration exemplified a vision that government has a role to play working with the private sector for economic development.

The CHIPS and Science Act’s objective to revitalize domestic tech manufacturing was in the service of national and economic security in the U.S. “That takes a government investment to be able to do that,” said Lisa Johnson, Bio-Forward’s executive director at the August event.

She also has introduced her share of bills that haven’t made it out of even one house of Congress, but in some of those she’s found a measure of victory. In 2023, the Securities and Exchange Commission finalized a rule aimed at curbing stealth investors who try to grab control of struggling companies out from under the owners and management in order to make a quick buck.

The rule had its origins in legislation that Baldwin sponsored in 2017 after the shutdown of a paper mill in Wisconsin’s Marathon County led the village where it was located to dissolve. While the bill didn’t advance, some of its language made it into the new SEC rule.

Baldwin’s office enlisted the support of the mill’s displaced executive, who praised the persistence and patience of the senator and her staff in seeing what became the new rule through to enactment.

The story reflects Baldwin’s success at allying with a wide range of constituents with a wide range of concerns — as well as with lawmakers across the aisle, like Republican Sen. David Perdue of Georgia, with whom she’d cosponsored the original legislative proposal.

“I fight for Wisconsin and only Wisconsin,” Baldwin told the debate moderators, “which means I’ll work with Republicans or Democrats, Republican administrations or Democratic administrations — to get the job done for Wisconsin but also stand up to them.”

Tying Baldwin to Biden

Hovde’s campaign has been largely built on three arguments: that the major federal legislation signed by Biden and championed by Baldwin has been not just ineffective but harmful; that immigration is out of control and hurting the country; and that Baldwin has been an ineffective politician with nothing to show for her 12 years in office.

Along with those critiques, he’s presented himself — the scion of developers in Wisconsin and the owner of a $3 billion bank in California, where he owns a $7 million home in Laguna Beach — as an experienced business operator who can bring a fresh face to Washington.

In his arguments on the economy and on immigration, Hovde has been largely in step with Trump. Hovde, who received Trump’s enthusiastic endorsement, spoke from the stage at the Republican National Convention in Milwaukee, even before handily winning his party’s nomination as the designated Senate candidate, and has appeared at numerous other Trump events.

In those public appearances, including last week’s debate, Hovde has attacked the incumbent almost constantly — shaking his head as she answered the questions posted by Wisconsin journalists at the event, then accusing her of lying repeatedly without offering specifics.

Wisconsin Democrats, meanwhile, have run TV ads citing more than a dozen instances in which independent fact-checkers have accused Hovde of lying in ads and public statements.

Hovde has railed against the signature bills Biden helped shape and signed — pandemic relief, the bipartisan infrastructure law and the Inflation Reduction Act.

At the debate Baldwin used Hovde’s opposition to the latter law to charge that Hovde “opposes efforts to negotiate the price of prescription drugs, saving patients and Medicare money.”

Provisions capping the out-of-pocket drug costs for Medicare patients and forcing drug companies to negotiate prices were part of the Inflation Reduction Act, she observed.

“My opponent would have voted against that measure. He’s said that many times,” Baldwin said. “We are seeing real reductions in prices that will save both patients money but will also extend the solvency of Medicare.”

Hovde took sharp offense to the assertion that he opposes negotiating drug prices, without addressing his opposition to the law that has made drug price negotiation possible. “I think drug prices are wildly too high and I’ll actually do something about it,” he said, without specifying what his response might be.

Inflation and immigration

Hovde has zeroed in on the 2021-22 inflation spike, blaming it primarily on the Biden legislation. “That’s why inflation got ignited,” he said at Friday’s debate, blaming Baldwin for “reckless spending.”

In addition to attacking Democrats on the economy, Hovde has echoed Trump’s campaign in criticizing Biden for ending a series of Trump executive orders restricting migrants.

At Friday’s debate, Hovde threw out figures for migrants in Biden’s first three years in office that added up to 10 million — a number that far exceeds any official estimates from federal agencies or non-government organizations that track immigration policy. He added, “We don’t know how many come in but it’s flooded our streets with fentanyl. We have criminals that have entered into our country and it’s created a humanitarian crisis.”

Political ads supporting Hovde have attacked Baldwin on the immigration issue.

According to the U.S. Department of Homeland Security, however, cartels mainly seek to move the drug across the border with the help of U.S. citizens. 

Baldwin has endorsed a bipartisan bill that the Biden administration reached with a group of conservative Republican senators but that the U.S. House Republican leaders killed at Trump’s urging.

Hovde has defended killing the bill, calling it a sham. “It wasn’t going to change any of the asylum laws or immigration laws at all,” he said.

Baldwin countered that the defunct legislation was “the toughest border bill that we’ve seen in years,” with provisions to add 1,500 border patrol agents along the Southern U.S. border. It also included technology to scan incoming vehicles for fentanyl.

She charged that Trump, with Hovde’s support, “wanted the political issue” of the immigration controversy. “They wanted the chaos,” she said. “They didn’t want a solution.”

With the attacks and counter-attacks, what started as a 7-point lead for Baldwin in the polls has narrowed considerably, with some polls showing the two neck and neck.

Despite that, University of Wisconsin-Green Bay political scientist Aaron Weinschenk says he believes a Hovde upset is unlikely. Baldwin easily won her last reelection bid in 2018, including in Republican areas like rural Richland and Lafayette counties, which Trump carried in the last two elections but which voted for Baldwin by more than 10 points. 

Baldwin “is pretty popular in Wisconsin,” Weinschenk said. “She’s like threaded the needle in appealing to people and you know different parts of the state that maybe you’d think of as being pretty Republican. It might be narrower than previous races, but I’d be surprised if she lost.”

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Health care advocate Laura Packard speaks at a Protect Our Care press conference Tuesday, Sept. 24. (Wisconsin Examiner photo)

Nearly 15 years after passage of the landmark federal law that expanded health care access across the country, health care remains a fixture on the ballot almost every November election.

This year is no exception. For advocates, health care is a central issue in both the national presidential campaign and in Wisconsin’s newly competitive contest for the state Legislature.

Sooner or later, virtually every American faces a struggle over how to pay for health care, Leslie Dach of Protect Our Care said during a visit to Madison Tuesday. Dach, a health advisor to President Barack Obama, founded Protect Our Care in 2017 to advocate for maintaining and strengthening federal health programs including the ACA.

“When you get sick, it takes over your life,” Dach said in an interview. “There’s no larger kitchen table issue in America. And it’s expensive, and a lot of people don’t have access to the care that they need, and so it’s a problem that affects really everybody — maybe not every day, but catches up with you at some point in your life.”

Besides being a personal issue, “it’s also a political issue now,” Dach added. The Affordable Care Act (ACA) remains under threat from Republican lawmakers. Some have also called for repealing all or part of the 2022 Inflation Reduction Act, including provisions making health insurance cheaper and allowing Medicare to negotiate the price of prescription drugs.

“The choices are very clear, and it’s both emotional and economic for people,” Dach said.

He was in Wisconsin for the second stop on the organization’s bus tour — a campaign to draw attention to the health care law’s increasing popularity and how it has been improved through laws such as the Inflation Reduction Act.

The Inflation Reduction Act extended tax credits that reduce the cost of health insurance policies that people buy on the ACA’s health insurance exchange through 2025.

Those credits have cut health insurance premiums by an average of $2,400 a year, said Joe Zepecki, Wisconsin representative for Protect Our Care, at a press conference outside the Protect Our Care campaign bus.

The 2022 law also capped insulin costs for Medicare patients at $35 a month and authorized Medicare to negotiate select drug prices. Starting in January, it will cap Medicare patients’ out-of-pocket drug costs at $2,000 a year.

“It is essential that everyone understands how they can benefit from these savings,” Zepecki said. “These policies are overwhelmingly popular. They touch nearly every household in America, whether you’re a senior or an individual struggling with a disability who’s having a hard time affording prescription drugs, a family purchasing your own health coverage, or a taxpayer who is sick and tired of lining the pockets of big drug companies.”

The Affordable Care Act also prevented insurers from rejecting patients or charging them higher premiums because of pre-existing health conditions — a practice that was routine until the ACA took effect.

“Insurance companies analyzed people with chronic conditions like cancer,” said Dr. Sophie Kramer, a Wisconsin physician for 35 years. “If you were born with a genetic heart condition or developed multiple sclerosis in your 30s, you were often out of luck.”

Prevention and protection

Without the ACA in place, “many people had to take the risk of no health insurance or opt for expensive, extremely high deductible plans,” Kramer said. Preventive care such as mammograms to detect breast cancer or colon cancer screenings are often treated as out-of-pocket costs until the ACA required coverage for a number of preventive health care measures, she added.

“The passage of the ACA changed this,” Kramer said. “Since 2014  … one in seven Americans and over 800,000 in Wisconsin have benefited from the ACA. This is tremendous progress.”

Despite that progress, she and others noted, Republican politicians have continued to bad-mouth the ACA and run on promises to repeal it.

“Donald Trump has talked about terminating the Affordable Care Act in this campaign,” said Wisconsin Attorney General Josh Kaul, who after first taking office in 2019 withdrew the state from a lawsuit to block the ACA and joined a friend of the court brief to support the health care law. “Let’s be clear, there’s no replacement plan for the Affordable Care Act.”

Kaul referred to Trump’s statement at the Sept. 10 debate with Vice President Kamala Harris, the Democratic candidate for president, about what he would do to replace the ACA after working to repeal it.

“Donald Trump recently said he has ‘concepts of a plan,’ after nearly a decade of his candidacy and as President,” Kaul said. “So there’s no plan to protect people with preexisting conditions. There’s no plan to ensure that costs remain low.”

Protections for people with preexisting conditions are at risk, he added, “and it’s clear that we’re facing further restrictions on access to safe and legal abortion.”

Laura Packard, a health care advocate taking part in the bus campaign who has supported the ACA for helping her survive and get treatment for a cancer diagnosis, said that after Trump’s statement about “concepts,” his running mate, Sen. J.D. Vance (R-Ohio) “laid out what some of those concepts are.”

A Vance proposal to replace preexisting condition protections with “high-risk pools” for those patients “would allow insurance companies to pick and choose their customers again,” Packard said. As one of 135 million Americans with a preexisting condition, she added, “if insurance companies had the choice, they would choose not to cover us. And we need health insurance to stay healthy and to stay alive.”

Zepecki said the Protect Our Care bus will travel 12,000 miles and visit 17 states “with a simple message — lower costs are here and we are not going back.”

Legislative endorsements

Advocating for the ACA is just one example of the way health care policy is on the political agenda this fall.

The Committee to Protect Health Care (a separate advocacy group) announced Tuesday a $500,000 ad buy and its endorsements in this fall’s Wisconsin Legislature races.

The committee consists of doctors, other health care professionals and other advocates. It is targeting a dozen Assembly and Senate races with digital video ads, direct mail and text messages directed at about 300,000 Wisconsin voters in the 12 districts.

The group’s health policy agenda includes expanding Medicaid, known as BadgerCare in Wisconsin, under the ACA and extending Medicaid coverage for new mothers for the first 12 months after they give  birth.

The committee’s priorities also include support for a state board empowered to reduce the cost of prescription drugs in Wisconsin, support for a paid family and medical leave program, and measures to ensure that decisions about reproductive care are made by  patients and medical providers. 

The group calls for repealing an 1849 law that caused abortion providers to cease practicing in Wisconsin for a year and a half, for fear of felony prosecution, until a judge ruled in 2023 that it did not pertain to abortion,  and enacting guarantees for access to contraception.

All of those measures have been proposed in the Wisconsin Legislature in one form or another by Democratic lawmakers but rejected by the Legislature’s Republican majority, the committee noted in its announcement.

Candidates supported by the ad campaign as well as the longer list of endorsed legislative candidates were selected for their support of the organization’s agenda, according to the committee.

“For too long, our state legislators have refused to expand BadgerCare and repeal our state’s archaic, harmful abortion ban,” said Dr. Ann Helms, a Committee to Protect Health Care Wisconsin leader and a neurologist. “These candidates have an opportunity to finally take action, granting health care access to tens of thousands of Wisconsinites and ensuring all women in the state can access the reproductive health care they need.”

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