A Healthcare Election? What the 2026 Midterms Mean for the Industry

By Leslie Isenegger, Head of Policy and Public Affairs, RC Resolve

The 2026 midterm elections delivered a significant shift in Washington, with Democrats taking control of both houses of Congress. Healthcare emerged as a defining issue of the election cycle. A KFF September poll found 60% of voters worried about affording healthcare. Democrats held a 42–22 advantage over Republicans on healthcare trust. 66% of voters supported Medicare for All, the highest share KFF has recorded since it began tracking the question in 2016. Healthcare accounted for the second-highest ad spending in competitive Senate and House races this cycle, according to the Cook Political Report, with most of that spending coming from Democrats. 

For workers with employer-sponsored coverage, costs were a direct motivator. As STAT’s Bob Herman reported the day before the election, “the unending financial pain of healthcare costs” was the driver. Family premiums are up 26% over five years, and employer-sponsored plan costs are projected to rise another 8% in 2027. The One Big Beautiful Bill Act included nearly $1 trillion in Medicaid cuts, paired with work requirements that experts projected would strip coverage from up to 10.1 million people by January 2027. Those provisions gave Democrats a direct contrast with Republican governance on healthcare that surfaced in nearly every competitive race. In rural states like Iowa and Maine, hospital closures tied to Medicaid funding reductions gave voters a local reference point. In Michigan, Abdul El-Sayed made Medicare for All the organizing principle of a winning Senate campaign. Healthcare costs, more than any single policy position, appear to have driven election outcomes. 

Beyond Congress, Democrats will have a majority of statehouses, holding 27 governorships to Republicans’ 20. 

State-level health policy implications are significant and are likely to advance on a faster timeline than federal action. KFF flagged that 30 states implementing Medicaid work requirements had governors on the ballot. Newly elected Democratic governors have both the political motivation and, in expansion states, significant administrative discretion to challenge or slow implementation before the January 1, 2027, effective date. Prescription Drug Affordability Boards (PDABs) had stalled in several Republican-led states. They now have a clearer path forward, and Ohio, Georgia, Iowa, and Texas are likely to revisit PDAB legislation in their 2027 sessions. 

On vaccines, the results create new complexity. New Democratic governors will face decisions about whether to maintain state mandates that diverge from revised HHS’ revised federal guidance, particularly on the restructured the childhood vaccine schedule. Reporting from state health policy trackers identified the vaccine issue as a mobilizing concern in several governor races, particularly in Ohio, Michigan, and Georgia. Overall electoral footprint of MAHA was limited. The MAHA PAC spent just under $10 million between January 2025 and August 2026, according to its filings, a fraction of what opposing trade groups spent in the same period. 

Industry Takeaway: What to Expect in Health Policy in 2027 

With a Democratic Congress and a Republican White House, opportunities for major new health legislation are limited. The 120th Congress is more likely to shape health policy through oversight, investigations, and must-pass legislative vehicles than through standalone reform. As STAT’s Daniel Payne and John Wilkerson reported the morning after the election, reversing Medicaid cuts and restoring ACA subsidies are likely first priorities. . The following issues are also likely to see some movement: 

PBM Reform. This is the one area with genuine bipartisan traction, and it was moving before the election. The Consolidated Appropriations Act of 2026 already  changed PBM revenue structures in Medicare and imposed new transparency and reporting requirements. Democrats will push further on fiduciary obligations for employer plan sponsors, spread pricing disclosure, and the FTC’s ongoing enforcement. Expect committee hearings on PBM pass-through rates and spread pricing to be hot topics on  the 2027 legislative calendar. 

MFN and TrumpRx Scrutiny. Congressional Democrats have identified the Administration’s 26 MFN drug pricing agreements  as a priority oversight target. As STAT reported, the terms of those agreements, specifically what manufacturers agreed to and what the federal government offered in return, remain largely undisclosed. House Energy and Commerce was already pushing the GAO to investigate TrumpRx before the election. Now that Dems have control and subpoena authority, those requests will no longer be optional. Manufacturers who participated should anticipate document requests and compelled testimony. Both parties have expressed interest in international reference pricing as a legislative tool, which creates a narrow opportunity for bipartisan legislation, but that window could close if oversight proceedings become adversarial. 

IRA Reform. Unfortunately for the pharmaceutical industry, any changes to the IRA will focus on expansion: shortening the exclusivity windows before drugs become eligible for Medicare negotiation, and potentially extending the negotiation framework to commercial insurance. The Small Molecule Penalty remains a point of contention given its documented effect on small molecule R&D investment decisions. Democrats are unlikely to address it in isolation, but it may emerge as a negotiating point in bipartisan discussions on FDA user-fee reauthorization, which is must-pass legislation in 2027. 

OBBBA Clawback. Reversing the Medicaid cuts enacted through the One Big Beautiful Bill Act is a stated top priority for House Democrats. Without 60 Senate votes, full repeal through regular order is not achievable. The more probable near-term approach may be targeted provisions attached to government funding legislation, alongside legal challenges from newly elected Democratic governors and attorneys general that could delay or enjoin work requirements before the January 2027 effective date.  
 
Restoration of the enhanced Affordable Care Act premium tax credits has broader bipartisan support. Those credits expired and contributed to a significant premium increase, making them a more viable candidate for a year-end funding package. Hospital systems have been actively building coalitions in Washington  to pursue Medicaid cut reversals.  
 
Separately, Democrats are expected to open oversight proceedings into the restructuring of federal health agencies under Secretary Kennedy, including staff reductions, changes to vaccine advisory infrastructure, and the terms of novel HHS arrangements with private sector entities. STAT’s Payne and Wilkerson describe this as a potential multi-year investigative focus. 

2027 Healthcare Winners and Losers

What Does This Mean for Healthcare Leaders: Telling the Bigger Story to a New Congress 

Healthcare has been at the center of the policy debate for the past two years, from the Medicaid changes in the One Big Beautiful Bill Act and the expiration of the enhanced ACA premium tax credits to the MFN drug pricing agreements, the restructuring of federal health agencies, and the revised childhood vaccine schedule. The shift in congressional control will likely amplify that focus on healthcare costs, which sit at the center of voters’ affordability concerns. It may also broaden the set of levers policymakers look to use. Beyond new legislation, expect oversight and investigations, must-pass funding and reauthorization vehicles, PBM and drug pricing reforms, and state-level action on issues such as Medicaid implementation and Prescription Drug Affordability Boards. 

Affordability is a goal shared across parties and across the healthcare ecosystem. The open question is how to get there—and that creates an important opportunity. A significant number of new members of Congress, along with new governors, will be forming their healthcare views, building their staffs, and seeking committee assignments in the coming months. Now-Q1 2027 becomes a critical moment for organizations to get in front of them early. Manufacturers, providers, plans, employers, and patient groups all have a role in helping new members see the bigger picture: how policy choices affect patient access to care, the pipeline of future innovation, and the unintended consequences that sweeping mandates, from any direction, can have on patients, providers, and the broader system. 

The organizations best positioned to shape the 2027 conversation will be those that build relationships with new members before positions harden, and that arrive with data, patient perspectives, and constructive solutions rather than objections alone.