Who Decides What in Your Health Care: The 2026 Midterm Vote

Monday, October 26 · Vote Your Health

Who Decides What in Your Health Care: The 2026 Midterm Vote

A map for the week before you vote.

The medical system in the United States is wrapped in complex, expensive and ineffective process. When I used to go to the polls, I knew the big players, Governor, legislators, but what I didn’t know was how their election would affect the health of the people I cared for, my friends and their families, my practice, the hospital system and me, through legislation. I also didn’t have awareness of the cost to the health of our state about the choices I was or was not making by voting for certain propositions or people. In medicine, I understand the choices and consequences. There are always tradeoffs. In these complex areas of policy there are tradeoffs as well. I just frankly did not know enough to judge how to make them. I realize many of you are in the same boat. Rather than just criticizing the system we have (easy to do right now, I’ll grant you) it’s time to take an active role by understanding and then acting.

This week I am attempting to clarify for you, the voter, why your vote counts this year.

Since September I have been writing about one thing: who gets paid in American health care, who gets heard, and who gets to decide. The pieces had different titles: trust, medical debt, respect, the closed screen. They are one argument. Their purpose is education that allows you to exercise your right to choose your own future.

Today is the map. Election day is November 3, and early voting is already open in many states, New York among them.

Most of what will happen to your health in the next four years will be decided by people on that ballot, or by people they appoint.

Here is who the players are and what they control.

The definitions

  1. Uninsured: no health coverage of any kind. The official number comes from the Census Bureau’s annual report, Health Insurance Coverage in the United States, which counts people who had no coverage for the entire year: 26.7 million, 7.9% of the American population, for 2025. That is a floor; it leaves out everyone who lost coverage for part of the year and got it back, or never got it back. The CDC asks a different question, whether you are uninsured right now, and gets 28.0 million people. If you are feeling vulnerable right now, I get it.

  2. Medicaid expansion: 40 of 50 states took the federal offer in the Affordable Care Act, available since 2014, to cover adults earning up to 138% of the poverty line. Under the 2026 guidelines that is people who earn $22,025 a year for one person, up to $45,540 for a family of four, with the federal government paying 90% of the cost. Ten states have not taken it: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. Roughly 11 million uninsured people live in those ten states. Texas alone has roughly 5 million people with no health insurance. (Those state counts are my arithmetic from the Census Bureau’s state rates and populations; the exact 2025 state figures are released October 29.)

  3. Medical board: each state has one. It licenses doctors and takes licenses away, so it decides who may practice and, increasingly, what tools may be used. The medical boards are now the target of lobbying by trade groups and companies over the rules for AI, and the question on the table is whether a doctor must be in the loop, standing between you and the answer, when you ask Claude, ChatGPT or another large language model about your own health.

  4. Scope of practice: state law on what each kind of clinician may do without a physician’s sign-off: nurses, pharmacists, physician assistants, and now software. Every signature the law requires that isn’t about safety is a fee, paid in money or in waiting.

  5. Billing code set: the list of codes every medical bill must use. For procedures and visits it is called CPT. It is privately owned by the American Medical Association, and everyone who bills pays for it, directly or inside the price of the software that sends the bill.

The federal layer

Five bodies decide most of what happens nationally. Two are elected. Three are run by people the President appoints, through the Department of Health and Human Services.

  1. Congress controls the money. It sets the Medicaid formula that decides how much Washington pays your state for every person covered, and it decides whether the marketplace subsidies that lower premiums continue. Last year Congress changed both. The Congressional Budget Office estimates the 2025 reconciliation law will mean 10 million more people will become uninsured by 2034, and the lapse of the enhanced premium credits adds another 4.2 million people. Congress is partisan, and the mindset of the party in power governs these decisions.

  2. The President of the United States appoints the heads of every federal agency that governs health and can change policy by executive order without a vote in Congress. The largest posts require confirmation by the Senate. All of the agencies below sit inside the Department of Health and Human Services, led since February 2025 by Secretary Robert F. Kennedy Jr. None of these people is on your ballot. The senators who confirm them are: 35 of those seats are up on November 3.

  3. CMS, the Centers for Medicare & Medicaid Services, runs Medicare, pays the federal share of Medicaid, runs the marketplaces where people in the states can buy coverage, and sets the payment rules every hospital and doctor lives by. It is led by Mehmet Oz, MD, confirmed April 3, 2025. It also names, by federal regulation, the billing code set the whole system must use. This July, in its proposed payment rule for 2027, it asked the public to describe “the harms or challenges” of the AMA’s control of that code set, citing “longstanding concern expressed over the Federal reliance on a private organization with such an obvious conflict of interest.” Thursday’s piece picks that up.

  4. FDA decides which drugs reach you, which devices, and which pieces of software count as a medical device and need its approval. That now includes the question of which AI tools do. Its commissioner, Marty Makary, resigned in May 2026; an acting commissioner is in place and a nominee is waiting for a Senate vote.

  5. NIH funds the research. The medical literature your doctor’s AI reads was paid for, in large part, by you, through it. It is led by Jay Bhattacharya, confirmed March 25, 2025.

Two agencies inside HHS, the FDA and the CDC, have each changed hands more than once since January 2025. The CDC’s first confirmed director of this term was removed a month after her confirmation; the second, Erica Schwartz, was confirmed in August 2026. The Surgeon General’s chair has been empty the entire term.

The state layer

This is the layer most people skip, and it is the one that touches your life most directly.

  1. The Governor appoints the state medical board, the Medicaid director, and in most states the insurance commissioner. She signs the budget that funds the state’s share of Medicaid, and she decides whether to expand it. If one person on your ballot controls your health care, it is this one.

  2. The Legislature sets Medicaid eligibility within federal rules, decides who may practice what (scope of practice), whether telehealth counts as a visit, what insurance must cover, and increasingly what AI may and may not do in medicine. Eighty-eight of the country’s ninety-nine legislative chambers are on the ballot this year.

  3. The Medical Board licenses and disciplines physicians. Its members are, in most states, appointed by the governor. Through their national federation, the boards are now drafting model rules on AI that works “with limited or no direct physician supervision,” which is to say, on whether you may use a tool for your own health without a doctor’s permission. That drafting is happening in a closed committee with no member of the public in it.

  4. The Insurance Commissioner approves rates, decides whether a plan’s network is adequate, and enforces what plans must cover. Elected in 11 states, appointed in 39. On the ballot this year in California, Georgia, Kansas, and Oklahoma.

  5. The Attorney General reviews hospital mergers, polices debt collectors, and enforces consumer protection against insurers and providers. Thirty attorneys general are on the ballot this year.

And your city

Cities don’t license doctors or regulate insurers; states do. What cities run is public health and public hospitals, which is where the uninsured are actually seen. New York City has its own Department of Health, a Board of Health appointed by the mayor that writes the city’s health code, and Health + Hospitals, the largest public hospital system in the country. It also runs Medicaid enrollment on the ground. So, the person who will decide whether you may use AI for your own health is a state appointee; the person who runs the hospital you’d go to without insurance is a city one. The pattern is the same most places: the state licenses, the city delivers.

What is on the ballot on November 3

Seven things, by the official counts:

  1. 36 governors

  2. 33 U.S. Senate seats, plus two special elections

  3. All 435 seats in the U.S. House

  4. 88 of 99 state legislative chambers, in 46 states

  5. 30 state attorneys general

  6. 4 insurance commissioners

  7. And, through the governors elected, the next appointments to every state medical board, Medicaid office, and in most states the insurance department

Your impact is larger than you have been told. The person you choose for governor chooses the people who will decide what you are allowed to know about your own body, and whether your neighbor keeps her coverage. That is one vote, and it is yours.

Where I stand

I am not a member of any party. No party’s platform was written with me in mind, and I would rather judge each candidate on what they will do about the things on this page than adopt an agenda somebody else assembled.

This is not a paid announcement. I am not raising money. Nobody is paying me to write this. I am a surgeon who took care of thousands of people with chronic disease and cancer in Arizona, was President of a national surgical society dedicated to the treatment of obesity and chronic disease, worked inside one of the largest health providers in the country, and finished a formal career inside a large medical device company. I have spent the last several years trying to describe a novel medical system in which health, not rescue, is the product. I have conflicts of interest like everyone in this field: I founded the companies and the charity that carry that work, and I write books about it.

None of them profit from how you vote.

Tomorrow, Tuesday: your state, all fifty, one page each. A roadmap that prepares you to vote on health. On Wednesday: seven questions to ask anyone who wants your vote. On Thursday: five gifts the public already paid for, and who can give them.

I would love to hear from you.

#VoteYourHealth #AlreadyPaidFor #FirstOpinion

Website: robinblackstone.com/voteyourhealth

Sources

  • U.S. Census Bureau, Health Insurance Coverage in the United States: 2025 (P60-291), Sept. 15, 2026: 26.7 million uninsured, 7.9%.

  • National Center for Health Statistics, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2025 (May 2026): “In 2025, 28.0 million people of all ages (8.3%) were uninsured at the time of interview.”

  • Congressional Budget Office, coverage estimates for P.L. 119-21 (publication 61367, Aug. 2025): about 10 million more uninsured in 2034. CBO letter to Wyden, Pallone and Neal, June 4, 2025: expiration of enhanced premium tax credits adds 4.2 million uninsured in 2034.

  • U.S. Department of Health and Human Services, 2026 Poverty Guidelines: 138% of the guideline is $22,025 for one person and $45,540 for a family of four.

  • 45 CFR §162.1002(a)(5): HIPAA standard code sets, including CPT “as maintained and distributed by the American Medical Association.”

  • Centers for Medicare & Medicaid Services, CY 2027 Medicare Physician Fee Schedule proposed rule (CMS-1848-P), 91 FR 43842, July 16, 2026, section II.H, Current Procedural Terminology (CPT) Request for Information.

  • Federation of State Medical Boards, Guide to Medical Regulation in the United States: boards are “typically made up of volunteer physicians and members of the public who are, in most cases, appointed by the governor.”

  • FSMB news release, May 19, 2026: Workgroup on the Regulation of Artificial Intelligence in the Practice of Medicine; charge includes AI performing clinical functions “with limited or no direct physician supervision.” Aguilar M., STAT, Oct. 14, 2026: 22-member workgroup met “behind closed doors”; roster obtained by STAT.

  • U.S. Department of Health and Human Services, Leadership (hhs.gov/about/leadership), accessed Oct. 25, 2026: Secretary Kennedy; CMS Administrator Oz; NIH Director Bhattacharya; CDC Director Schwartz; FDA Acting Commissioner Kyle Diamantas; Surgeon General vacant. Senate confirmations: Kennedy, Feb. 13, 2025; Oz, Apr. 3, 2025; Makary and Bhattacharya, Mar. 25, 2025; Monarez (CDC), July 29, 2025; Schwartz (CDC), Aug. 5, 2026. Makary resignation: NPR, May 13, 2026.

  • Ballotpedia: 36 gubernatorial seats (State executive official elections, 2026); 33 Senate seats plus two specials and all 435 House seats (United States Congress elections, 2026); 88 of 99 legislative chambers in 46 states (State legislative elections, 2026); 30 attorney general seats (Attorney General elections, 2026); insurance commissioner elected in 11 states, appointed in 39, on the 2026 ballot in CA, GA, KS, OK (Ballotpedia News, Apr. 30, 2026).

The week before the vote, day by day →