Taxes and policy

What the midterm elections could mean for your practice

Most of the 2025 tax changes are settled. Your health insurance, your clients' coverage, and your Medicare telehealth sessions are still on the table. Here is what the people elected on November 3 get to decide, with no opinions on who should win.

Why a midterm matters to a practice of one

On November 3, every House seat and 35 Senate seats are up, along with 36 governorships and 145 statewide measures. Midterms get a fraction of the attention a presidential year gets, and they decide who writes the rules you run your practice under: tax law, Medicaid and Medicare rules, telehealth coverage, and whether the people who buy their own health insurance get help paying for it.

You are a business owner, an employer for some of you, and a health care provider all at once. Few voters sit at that intersection, and few ballots touch it as directly as this one. Here is what is already settled, what is still being debated, and who gets to decide.

Your taxes: most of the big changes are already law

The One Big Beautiful Bill (signed July 4, 2025) settled a lot of what therapists were waiting on. The 20% qualified business income deduction is now permanent, with a wider phase-in range starting in 2026. Today's tax brackets are permanent. The standard deduction is $15,750 for single filers and $31,500 for joint filers, indexed to inflation. The SALT cap is $40,000 through 2029, then drops back to $10,000. The 1099-NEC threshold rises from $600 to $2,000 in 2026, so fewer small contractor payments trigger a form. 100% bonus depreciation is back. We covered the details in how the One Big Beautiful Bill impacts your private practice taxes and whether it changes how you pay estimated taxes in 2026.

What the election changes is what happens next. The people elected on November 3 write the next tax bill, decide whether the pieces with end dates get extended, and oversee how the IRS carries out this one.

What's being proposed

House leadership has discussed a second reconciliation bill for 2027. The Republican Study Committee's framework centers on affordability, housing, and health care, and includes a push to expand health savings accounts. Other members want to revisit the parts of the 2025 law they voted against, starting with the Medicaid and ACA provisions, and would use hearings and spending bills to slow or soften them. Neither side has proposed repealing the tax provisions, and a presidential veto would stand in the way of a repeal in any case.

What lands before January no matter who wins

Government funding runs through December 11. The temporary 2.5% Medicare physician fee increase the 2025 law gave for 2026 expires at year end. Several health extenders expire December 31. The year-end package is where Congress handles these, and the November result shapes whether it is a short patch or a bigger deal.

What this means for you

Plan your 2026 return and your Q4 estimated payment on the law as it stands. The QBI deduction, the brackets, and the standard deduction are set. Nothing that passes after the election changes your 2026 filing unless Congress makes it retroactive, which is rare. The SALT cap and a few other provisions have end dates in 2029 and 2030, and the Congress elected in 2028 deals with those.

Health coverage and reimbursements: where the election hits hardest

Your own health insurance

If you buy coverage on the ACA marketplace, you already felt this one. The enhanced premium tax credits expired at the end of 2025 after Congress declined to extend them. KFF found that enrollees who kept the same plan saw premiums rise 114% on average. Net premium payments rose 58%, from $113 to $178 a month, as people traded down to bronze plans. Average deductibles jumped 37%, to $3,786. Paid enrollment fell from 22.1 million in 2025 to 19.2 million in February 2026, and could end the year closer to 17.5 million. People earning just above four times the poverty line, which is where many solo practitioners sit, made up 3% of 2025 sign-ups and 27% of the drop.

Both parties say the cost is the problem. They disagree on the fix. Democrats propose restoring the enhanced credits, which capped premiums at 8.5% of income for people above four times the poverty line, and would make it an early priority. Republicans argue the enhanced credits let insurers raise prices because taxpayers absorbed the increase, and that they invited improper enrollment: a GAO sting obtained subsidized coverage for fake applicants, and the Paragon Health Institute estimates 6.2 million 2026 sign-ups were improper, a figure the American Hospital Association disputes. Their proposal pairs expanded health savings accounts with a redesigned subsidy built on the original ACA formula. The lines are not purely partisan: nine House Republicans joined Democrats to advance a three-year extension in December. The Congress seated in January chooses between these approaches, or leaves things as they are, which is also a choice.

Whichever way it goes, open enrollment for 2027 coverage opens November 1 and runs through January 15 in HealthCare.gov states, with December 15 the cutoff for coverage that starts January 1. Build your 2027 income projection now, since your subsidy is based on it and the 2025 law requires full repayment of excess credits.

Medicaid

Medicaid is the largest source of financing for behavioral health care in the country, covering about a quarter of all spending, and the 2025 law's biggest Medicaid changes have not taken effect yet. Starting January 1, 2027, expansion states must require 80 hours a month of work or qualifying activity for adults 19 to 64, and must re-check eligibility twice a year instead of once. Retroactive coverage shrinks from three months to one. Starting October 2028, states must charge copays of up to $35 for some services, though mental health and substance use care are exempt. People with a disabling mental disorder who are classified as medically frail are exempt from the work requirement. CBO projects the Medicaid changes leave 7.5 million more people uninsured by 2034. KFF's read is that most affected adults already work or qualify for an exemption, so the main risk is paperwork, which means coverage churn for clients and more denials and resubmissions for providers who panel with Medicaid.

What elected officials could do here: Congress could delay the start date or widen the exemptions through spending bills, something members from both parties in states with large rural Medicaid populations have raised. It could also keep the schedule and add funding for program integrity, which supporters say protects the program for the people who need it most. Your governor and state legislature decide the part you will feel first: how simple the work-reporting system is, how much help enrollees get at renewal, and whether reimbursement rates for therapists keep pace. Those are state budget decisions made in 2027 by the people elected this November.

Medicare and telehealth

This one is settled through 2027 and open after that. Congress extended Medicare telehealth flexibilities through December 31, 2027, including the delay of the six-month in-person visit requirement for telemental health. Clinical social workers, counselors, and MFTs who bill Medicare can keep seeing clients by video from home through next year. The CONNECT for Health Act and the Telemental Healthcare Access Act would make this permanent, with sponsors from both parties, and the next Congress decides whether they move. Separately, CMS has proposed a 1.68% cut to the 2027 physician fee schedule conversion factor, mostly because the 2.5% bump from the 2025 law was for 2026 only. The final rule is expected in November, and a fix would come from Congress.

Private insurance panels

No bill on the table changes commercial reimbursement rates directly. What moves them is the risk pool. When marketplace enrollment shrinks and deductibles climb, more clients hit their deductible later in the year or skip care, and insurers facing a sicker pool seek bigger rate increases and sometimes leave markets. Mental health parity enforcement is another lever the next Congress and administration control.

Your clients

The biggest effect on your practice may show up in your caseload before it shows up in a tax form. Three things to watch.

Coverage churn. When a client loses marketplace coverage because the premium doubled, or loses Medicaid because a form was late, they tend to pause therapy or ask about sliding scale. Our September piece on the 2025 law walked through options: sliding scale, adjusted session frequency, group formats, referrals to lower-cost care, and keeping an emergency fund for a slow quarter. Those still apply, and the 2027 Medicaid timeline gives you a year to plan.

Election stress itself. In the APA's Stress in America survey ahead of the 2024 election, 77% of adults named the future of the nation as a significant source of stress and 69% named the election. Therapists told SimplePractice they saw more election-related anxiety in sessions and, for some, more appointments. Expect a similar wave in the next two weeks, and expect it to land differently for clients whose coverage, immigration status, or rights are on the ballot.

Demand. KFF polling finds 6 in 10 voters worry about affording care, and costs are the top health issue across parties. Clients who keep coverage may still carry a $3,786 deductible into January. Cash-pay and superbill practices feel this as clients spacing out sessions. Insurance-based practices feel it as more pre-deductible collections and more balance tracking.

Down ballot: what your state decides

State races decide your licensing board's budget, your Medicaid reimbursement rates, your state income tax, and whether telehealth across state lines gets easier. Pick your state to see the races, the Medicaid and marketplace rules that apply to you, and the statewide measures worth reading before you fill in the oval.

What to do this week

Vote, if you have not already. Many states allow same-day registration and most have early voting through this weekend. Vote.gov has your state's deadlines and polling locations.

Read your whole ballot, especially the state measures and the state legislative races. State lawmakers set Medicaid rates and licensing rules, and those races are often decided by a few hundred votes.

Build your 2027 income projection now if you buy marketplace coverage. Open enrollment runs November 1 to January 15 (December 15 for a January 1 start), your subsidy depends on that number, and overestimating is cheaper than underestimating under the new repayment rules.

Plan your Q4 estimated payment on current law. The January 15 deadline lands the same day open enrollment closes, and nothing Congress does in December will change what you owe for 2026.

Flag Medicaid clients for a 2027 conversation. Work requirements and twice-yearly eligibility checks start January 1, 2027 in most expansion states. A client who knows what paperwork is coming is a client who keeps coverage.

We will publish a follow-up after the results are in with what the outcome means for your practice, the way we did after the 2025 tax law passed.

This article is for informational purposes only and is not legal, business, or tax advice. Heard does not endorse candidates or ballot measures. Figures from KFF, the Congressional Budget Office, NAMI, NASW, CMS, Ballotpedia, and state election offices, as of October 27, 2026.