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February 24, 2021
US Health Care Reform
David K. Jones
Sep 15, 2021
Jun 29, 2021
Apr 28, 2021
Back to The Milbank Quarterly Opinion
The 2022 midterm elections already loom large over the Biden administration and Congressional allies. What the administration is able to accomplish during the next four years to address the health and economic impacts of COVID-19, increase health insurance access, slow climate change, eliminate racial inequities in maternal mortality, and a host of other issues largely hinges on the 2022 elections. This is true at the start of every new presidential term but is especially so now, given the incredibly razor-thin margins in both chambers. What can we expect?
The 2022 midterms are particularly important as they will be the first elections following the 2020 census. It is hard to predict exactly what effect the new allocation of House seats will have on partisan control and the Biden agenda because so much depends on which states gain and lose seats. This will be shaped by who the census counts. Within hours of taking office, President Biden signed an executive order to make sure everyone is included, regardless of immigration status.
Current projections suggest that traditionally blue states are likely to lose seats, including two in New York, one in California for the first time in its history, as well as in Illinois, Michigan, Minnesota, Ohio, Pennsylvania, and Rhode Island. These seats will mostly go south and west, with Arizona, Colorado, Montana, North Carolina, and Oregon each possibly gaining one seat, Florida gaining two, and Texas gaining three.1
The practical impact of these shifts depends on how states redraw their district maps. Most use an independent commission, have increasingly strict guardrails around legislative redistricting, are led by Democrats, or are already gerrymandered. This suggests that the musical chairs of House seats does not inherently pose a threat to President Biden’s ability to advance his agenda. Even if Republicans do make gains in the short term, the demographics of the people moving suggests that Democrats may soon be winning in red states such as Florida, North Carolina, and Texas. These trends might not help President Biden pass legislation today, but will make it that much harder for Republicans in the future to undo anything his administration does accomplish.
The conventional wisdom is that the party winning the presidency is likely to suffer big losses in the subsequent midterm elections. History shows that the worst losses are often during a president’s first term: Republicans lost 39 seats in 2018, Democrats lost 69 seats in 2010, and Democrats lost 60 seats in 1994.2
But there are also compelling counterexamples suggesting President Biden and Congressional Democrats have a shot at maintaining their majorities. The most recent exception was George W. Bush’s first term in 2002, which happens to be the last time that the census coincided with the beginning of a president’s first term. Republicans held 221 seats in the House – which is almost identical to the Democrats’ current majority of 222 – and were able to increase their margin to 229 seats. The previous exception to the trend of new presidents losing seats in Congress was in 1934. Franklin Roosevelt won a landslide victory in 1932, and Democrats won nearly 100 additional seats two years later.2
Joe Biden is not a war-time president in the traditional sense, though today’s economic, health, and social battles parallel the challenges faced by Presidents Roosevelt and Bush. They each were rewarded in the subsequent midterm and presidential elections for what the country perceived as strong leadership in response to the Great Depression and the 9/11 attacks, respectively. President Biden could experience a similar boost if voters see substantial progress on today’s crises.
These historical comparisons can only tell us so much about our current moment. Yes, George W. Bush followed a president who had been impeached and won a controversial election in which the losing side felt cheated. But Al Gore conceded graciously, and the country came together after 9/11 in a way that is hard to imagine today. Roosevelt’s gains were largely driven by the coalition between northern and southern Democrats as the effects of Jim Crow and the Great Migration reshaped the country.
The only other president since the Civil War to see his party gain seats in the midterm elections of his first term was also named Roosevelt. There are not a lot of parallels between President Biden’s situation today and Teddy Roosevelt’s success in the 1902 midterm elections, particularly as Roosevelt had just recently taken office following the assassination of President McKinley. But the present moment highlights a point that is incredibly important for the long-term work of developing policies aimed at improving population health.
Like Biden in 2022 and Bush in 2002, Roosevelt’s first midterm election in 1902 coincided with the census. The key difference was that a cap had not yet been set on the number of people in the House of Representatives. Both major parties gained seats because the size of Congress itself grew. This institutional adaptability was critical as the country was rapidly changing with industrialization and massive waves of immigration. The US population increased 25% between the censuses in 1880 and 1890, and then another 20% between 1890 and 1900.3
Legislators from rural areas became worried that their influence would diminish as the size of Congress grew with increasingly large cities. They blocked reapportionment after the 1920 census and successfully pushed for a compromise in 1929 that permanently capped the number of seats in the House at 435, the number at the time. As a result, the number of legislators in Congress has not changed in nearly a century, even though the US population has tripled.3
The algorithm that is used to allocate seats results in quirks such that the single member of Congress from Montana represents nearly 1 million people, while each of the two members from Rhode Island represents 525,000 people, even though the populations of the two states are very similar. Representation in Congress is grossly out of whack with peer countries and is inherently inequitable. Research shows that legislators in larger districts are more likely to follow the wishes of interest groups and louder voices, even if this conflicts with what a majority of their constituents prefer, and results in critical needs remaining unaddressed.4
Modeling suggests that the right number for today’s population is around 600. Approaches such as the Wyoming Rule and the “root square method” have been proposed to determine what the right number should be and how to allocate these seats.3 Neither party would be inherently advantaged by such an increase, in part because smaller districts are harder to gerrymander. An estimated 25% of seats would be highly competitive each cycle, compared to about 5-10% today.4 Candidates and parties would have much more incentive to talk to the middle of the partisan spectrum rather than just the extremes.
Increasing the size of Congress may not seem like a public health issue, but it epitomizes the concept of the “political determinants of health.”5 Political institutions need to be designed such that the people with power to make the policies affecting public health are responsive and accountable to everyone, including vulnerable populations. Removing the House cap will not solve all representation problems, but it is one of the most important long-term investments that President Biden and Congress can make to improving our politics, and in turn, to improving policies affecting population health.
David K. Jones, PhD, is an associate professor in the Department of Health Law, Policy and Management at Boston University School of Public Health. His recent book, Exchange Politics: Opposing Obamacare in Battleground States (Oxford University Press, 2017), focuses on how states made decisions around what type of health insurance exchange to establish as part of the Affordable Care Act’s implementation. He is working on a new book using Photovoice to examine the social determinants of health in the Mississippi Delta, retracing Robert Kennedy’s steps in the region. He also studies Medicaid, Children’s Health Insurance Program, and health reform in France. He has been cited in the New York Times, the Washington Post, and the Wall Street Journal, among other places. He testified before the Michigan legislature’s House Health Policy Committee during its consideration of a health insurance exchange. He has been awarded the Association of University Programs in Health Administration’s John D. Thompson Prize for Young Investigators, AcademyHealth’s Outstanding Dissertation Award, and the Boston University School of Public Health Excellence in Teaching Award. Jones earned a PhD from the University of Michigan in health services, organizations, and policy. He holds a master of arts in political science from the University of Michigan, a master of science in public health from the University of North Carolina at Chapel Hill, and a bachelor of arts from McGill University. September 2020
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