Welcome to the summer edition of the AMA's Very Influential Physician (VIP) Insider. Read on for details about these topics:

• Hotline's initial 2026 House power rankings
• As redistricting war looms, Republicans have more plausible gerrymandering targets than Democrats
• The August recess is upon us – tell your members of Congress it's time to Fix Medicare Now!
• Budget reconciliation bill worsens access to care, includes significant health care funding cuts

Hotline's initial 2026 House power rankings
By James A. Downs of the National Journal

House Republicans enter the 2026 cycle with a three-seat majority, and they hope to defy history by maintaining control of the chamber. That won't be easy: Since World War II, the party in power has lost more than 25 seats on average in midterm elections, per FiveThirtyEight.

But Democratic and Republican operatives concede that the battlefield has shrunk and, at this moment, neither party is bracing for a 2018-like wave, even if history suggests it might be a Democratic-leaning year. Democrats currently lead on the aggregate generic ballot by 3 points.

Redistricting once again influences the map. Republicans are expected to gain seats in Ohio and Texas, while the White House has urged several other Republican-led states across the country to remap. California Gov. Gavin Newsom has threatened a redistricting plan of his own, but the state puts several legal barriers in his way.

Despite the likely gains via redistricting, Republicans face the prospect of turning out voters without President Trump on the ballot, a challenge that has dogged the party in midterms and special elections since his ascent in 2016.

All told, six months into the election cycle, there's more uncertainty than clarity. What is clear, though, is that Republicans will be tasked with defending the passage of their budget bill. While certain provisions in the bill—such as eliminating taxes on tips and overtime—poll favorably, its overall image is underwater. Democrats are sure to focus on the health care and cost-of-living aspects of the measure.

As Hotline has cautioned in the past, these rankings are an assessment based on a snapshot in time, and they represent an initial benchmark of the competitive battlefield. These rankings do not forecast which party might win the majority but rather consider each race on its individual merits. They are based on conversations with strategists, consultants, and campaigns in both parties.

1. Nebraska's 2nd: Open (R)
Democrats rejoice as centrist Rep. Don Bacon is calling it quits at the end of the term. Since his election in 2016, Democrats have tried, and tried again, to defeat the Air Force veteran to no avail, despite the blue tinge to the district. Bacon won by about 6,000 votes last cycle, even as late polling showed him in trouble. Bacon doesn't grow on trees, and unless Republicans find another superstar, this is undoubtedly the most vulnerable seat in the country.

2. Colorado's 8th: Rep. Gabe Evans (R)
Winning reelection as a freshman is one of the most difficult feats in politics. Evans, one of the GOP's strongest recruits last year, faces a challenge in a two-cycle-old district that has had two representatives. No candidate—former Rep. Yadira Caraveo or Evans—has cleared 50 percent in an election, and it's likely to be another knife fight in a dark alley. Evans has a few things going for him right now: the six-way Democratic primary that includes Caraveo and other elected officials, as well as a fundraising advantage. Despite her name recognition, Caraveo may not be the strongest candidate to take on Evans, as she's reportedly struggled with her mental health and faces claims of staff mistreatment by former aides.

3. California's 13th: Rep. Adam Gray (D)
This Central Valley seat has produced some of the closest elections in each of the last two cycles, and a rightward shift at the top of the ticket likely ensures that again. Gray emerged victorious after an unsuccessful 2022 campaign. The Republican field is not clear: Ceres Mayor Javier Lopez was thought to be a compelling candidate, but he raised less than $100,000 during the last quarter. No matter what the matchup is, Gray will have a fight ahead of him.

4. Pennsylvania's 7th: Rep. Ryan Mackenzie (R)
Mackenzie snuck past Democratic Rep. Susan Wild last year amid a Democratic collapse in Pennsylvania, making him one of this cycle's most vulnerable candidates. No clear front-runner has emerged in an eclectic field of Democrats. Republican-turned-Democrat former federal prosecutor Ryan Crosswell, Wild-endorsed energy-engineering manager Carol Obando-Derstine, and Northampton County Executive Lamont McClure, who has struggled to raise money, are all running. Mackenzie had a solid second fundraising quarter, and he'll need every penny to win a second term.

5. Iowa's 1st: Rep. Mariannette Miller-Meeks (R)
After the closest race in the country here last year, Democrats are finally convinced they can defeat Miller-Meeks. To do so, they'll run back Christina Bohannan, a former state representative who will take her third crack at the Republican. The congresswoman has long struggled with her base, but Republicans say she's worked to improve her image. Retread candidates are not always the most successful, but Miller-Meeks ran and lost three times before a 2020 victory. The last time they squared off in a midterm, in 2022, Miller-Meeks bested Bohannan by 7 points. Continue reading  

As redistricting war looms, Republicans have more plausible gerrymandering targets than Democrats 
By Kyle Kondik of Sabato's Crystal Ball 

Earlier this week, the Texas state legislature started a special session that is slated to address congressional redistricting. At the behest of President Trump's administration, Texas Republicans will consider creating a map that goes further than their preexisting partisan gerrymander, which produced a GOP delegation advantage of 25-13 in its two cycles of existence.

Armin Thomas of Split Ticket showed how Republicans could attempt to net an additional five seats out of Texas by targeting a couple of currently Democratic districts in South Texas (something we noted when news of a possible Texas re-gerrymander broke a month ago), as well as a couple of additional seats in Houston and another in the Dallas-Fort Worth Metroplex.

Republicans wouldn't necessarily be guaranteed to win all of these seats in the context of 2026, particularly if it's a Democratic-leaning midterm environment, but they certainly could. This caveat is worth remembering throughout this article: Just because a map is redrawn to produce a certain outcome does not mean that it will definitively produce that outcome, nor does the possibility of a mid-decade redraw necessarily mean such a redraw actually will occur (mid-decade redraws not forced by courts are not unprecedented, but they also are not common). And the potential exists for lawsuits on any new district map, based on both the particulars of state law (which differ, as you'll see) as well as federal law, such as complying with the Voting Rights Act when drawing certain minority districts. But there are no federal prohibitions on partisan gerrymandering—there could be, and there perhaps should be, but there are not. Members of Congress also often do not want to see their districts changed, but they don't have a formal role in drawing their districts. State legislators, though, may eventually want to be members of the U.S. House themselves, which could impact their thinking and prompt them to consider options other than maximizing party gains.

Texas draws districts in a traditional way, with the state legislature drawing a map and sending it to the governor for approval. Several decades ago, the state was known for Democratic gerrymanders; now it is known for Republican ones. Famously, Texas Republicans re-drew their state's map in 2003, replacing a previously court-drawn map that was similar to a Democratic gerrymander from the 1990s with their own gerrymander. Paul Kane of the Washington Post recounted the history in a column over the weekend. Republicans ended up netting six seats from Texas in 2004. There is no federal prohibition on mid-decade congressional redistricting, although some states do or do not allow it (or are unclear about it). Texas allows it.

The Texas re-gerrymander is, understandably, infuriating Democrats, and Democratic leaders have been making noise about trying to compensate for losses in Texas by trying to gerrymander in states where they control the state government. Continue reading 

August recess is upon us – tell your members of Congress it's time to Fix Medicare Now!
With the House of Representatives adjourning for the annual August recess and the Senate about to follow suit – now is the perfect time to take advantage of the unique opportunities to engage with their members of Congress while they're "back home."

Find out how you can take advantage of the August recess and tell Congress to Fix Medicare Now! 

Earlier this month, the AMA hosted a webinar featuring Lindsey Brill, Sr. Lobbyist in the AMA's department of Congressional Affairs, who provided an update on the current state of Medicare physician payment legislation on Capitol Hill and what lies ahead this fall and advocacy expert David Lusk of Key Advocacy who provided best practices for engaging legislators in-district including how to prepare for in-district legislative meetings, host Members of Congress at site visits, and interacting with elected officials online.

To make these interactions with your legislators as impactful as possible, the AMA has developed an online August recess resources site that is your one-stop-shop for toolkits, legislative calls to action, issue briefs, infographics and detailed information on scheduling and preparing for legislative meetings and other in-district opportunities. 

It's not too late to fight for your practice and your patients - Please take advantage of the August recess to let your members of Congress know that it's time to Fix Medicare Now!  Everyone agrees that the Medicare physician payment system is broken – let's do something about it! 

Budget reconciliation bill worsens access to care, includes significant health care funding cuts
The One Big Beautiful Bill (OBBB) Act of 2025 (H.R. 1), the massive budget reconciliation bill implementing many of the administration's top legislative priorities, was signed into law on July 4. The bill includes significant funding cuts and policy changes to Medicaid and the Health Insurance Marketplaces, Medicare physician payment, and medical student loans, among other health care related items:

• Medicaid. The OBBB creates new administrative requirements and conditions on eligibility (including work requirements) for patients seeking to enroll in or maintain Medicaid coverage and restricts states' ability to use provider taxes to finance their Medicaid programs.
• Access to health insurance coverage through the Affordable Care Act (ACA) marketplaces. The OBBB imposes verification requirements for patients receiving premium tax credits, including pre-enrollment verification requirements that will effectively end automatic re-enrollment for these patients. The OBBB does not address the scheduled expiration of enhanced tax credits at the end of 2025.
• Federal support of medical student loans. The OBBB, in part, removes the ability for medical students to receive Federal Direct Stafford loans and Federal Direct PLUS Loans, caps the amount that can be borrowed for school, and limits federal student loan borrowers to only two repayment options.
• Medicare physician payment reform. The OBBB includes a temporary one-year 2.5% conversion factor update for 2026, replacing the original House bill that called for a 75% MEI inflation update in 2026 followed by annual 10% MEI increase, leaving no permanent, inflation adjusted payment fix.

In a statement issued on July 3, AMA President Bobby Mukkamala, MD, said, "Today is a sad and unnecessarily harmful day for patients and health care across the country, and its impact will reverberate for years. Care will be less accessible, and patients may simply forego seeing their physician because the lifelines of Medicaid and CHIP are severed. This is bad for my patients in Flint, Michigan, and it is devastating for the estimated 11.8 million people who will have no health insurance coverage as a result of this bill. The American Medical Association's mission is promoting the art and science of medicine and the betterment of public health. This bill moves us in the wrong direction. It will make it harder to access care and make patients sicker. It will make it more likely that acute, treatable illnesses will turn into life-threatening or costly chronic conditions. That is disappointing, maddening, and unacceptable."

Be sure to follow all the AMA's Physician Grassroots Network social media accounts for all the latest news on physician advocacy and what you can do to make sure your voice is heard on Capitol Hill. 

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