VIP Insider: December 2025

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

Grassroots webinar: “Why are you telling stories? … and if you aren’t, here’s why you should!”
The separate political realities of red, blue, and purple America
4 “Big, Beautiful Bill” that will reshape care in 2026
Rust on the Midterm Iron Law? Voters expectations for 2026

Grassroots webinar: "Why Are You Telling Stories? ... and if you aren't, here's why you should!"
Effective storytelling is central to successful policy advocacy, yet its impact reaches far beyond the legislative arena. In our professional and personal lives, stories are how we connect with others, shape perceptions, and inspire action. Despite this, many people overlook that compelling storytelling is both an art and a science—one grounded in proven methods and rooted in the way our brains are naturally wired. We are biologically predisposed not only to absorb stories but also to organize our experiences into narrative form, influencing how we understand the world and persuade those around us.

Join us on Thursday, January 18 at 8pm ET

In this engaging training session, participants will discover why storytelling is embedded in our neurological makeup, predating even spoken language. We will examine scientific insights that reveal the power of both story thinking and storytelling and introduce the core elements that make a narrative truly effective. The session will also explore how physician advocates can tailor their stories to different types of legislators, ensuring messages resonate regardless of the audience.
By the end of the training, AMA physician advocates will be equipped with practical tools to craft stories that resonate, motivate, and ultimately drive meaningful outcomes in their advocacy efforts.

The separate political realities of red, blue, and purple America
By Charlie Cook of the National Journal

Most everyone has embraced the current partisan configuration that has been in place since 2016: 24 red states tilting toward Republicans, 19 blue states leaning Democratic, and seven purple states in the middle, where battles are often fought and won.

President Trump carried all 24 red states in each of the last three elections, whereas all 19 blue states supported the Democratic nominees. In the seven purple states, Trump carried six in 2016: Arizona, Georgia, Michigan, North Carolina, Pennsylvania, and Wisconsin; Hillary Clinton prevailed in Nevada. Four years later, Joe Biden won all but North Carolina, then in 2024 Trump swept all seven.

These red, blue, and purple distinctions are not gimmicks or cliches; the groups are remarkably distinct, and their identities extend far below the presidential line on the ballot.

In the 24 red states, Republicans hold all 48 Senate seats, 22 out of 24 governorships, and all eight lieutenant-governor offices that are elected separately from the top of the ticket. Republicans hold all 21 popularly elected attorney-general and secretary-of-state offices, and majorities in all 23 partisan state Senate and House chambers (Nebraska’s legislature is both nonpartisan and unicameral). Last but certainly not least, Republicans hold 131 (77 percent) of the 171 U.S. House seats in the red states.
In the 19 blue states, Democrats hold 37 of 38 Senate seats, 17 of the 19 governorships, and five of the six separately elected lieutenant governorships. They claim 15 of the 16 popularly elected attorneys general, all 11 popularly elected secretaries of state, and majorities in both the state Senate and House chambers in 18 of 19 blue states. Democrats have 120 (66 percent) of the 183 U.S. House seats in those blue states (note Democrats’ smaller share in their states).
In the seven purple states, Democrats hold 10 of 14 Senate seats. Democrats also have five of seven governorships, five of seven attorney-general offices, and five of six popularly elected secretary-of-state offices. But curiously, Republicans have the upper hand in those seven states in terms of U.S. House seats, 49 out of 79 (62 percent). The GOP also holds majorities in five of the seven state Senate chambers and six out of seven state House chambers, as well as two out of the three separately elected lieutenant governorships.

These results raise some interesting questions. First, why do Republicans perform better than Democrats in the U.S. House, state Senate, and state House seats in the purple states, even though Democrats do better at the U.S. Senate and gubernatorial level in those seven?

Second, why do Republicans win a higher share of state legislative seats in blue states (35 percent of state Senate seats, and 38 percent in state Houses), than Democrats do in red states (23 and 27 percent, respectively)? Republicans also hold majorities in two blue-state legislative chambers (both in New Hampshire). In contrast, Democrats hold no such majorities in red states.

My hunch is that these results are the product of decades of Republicans investing far more money in local, county, and state party-building than Democrats, with the Obama years a key period when his party could and should have done much more. Indeed, the last time Democrats made down-ballot party-building a priority was during the years 2005-2009, when Howard Dean chaired the Democratic National Committee.

Another theory is that Republicans have done a better job of leveraging culturally conservative local issues down the ballot, while Trump has been more of a drag higher on the ballot. Still another idea is that GOP primaries have nominated too many MAGA-oriented candidates in those Senate and gubernatorial races who have not gone over so well with swing voters or who have dampened enthusiasm among non-MAGA Republicans.

While this 24-19-7 configuration has held up across three elections, the list of "tipping point" states is hardly carved into granite and, in fact, has evolved substantially over the last 25 years. If we look at presidential elections from 2000 through 2012, rank the states by victory margin on a percentage-point basis, and factor in the Electoral College votes required to reach 270, Florida and Ohio were among the tipping-point states in four elections; Kentucky, New Mexico, and Tennessee appeared three times; and Virginia twice. Indiana, Iowa, Louisiana, Missouri, Montana, New Hampshire, New Jersey, and Oregon each made solo appearances.

None of those states figured into the tipping-state math in the last three elections.

The blue state that's least like the others could well be New Hampshire. On the one hand, Democrats won New Hampshire in eight of the nine presidential elections from 1992, the exception being 2000 when the Granite State sided with George W. Bush. But below the top of the quadrennial ballot, Republicans have now won the governorship in five consecutive elections (New Hampshire and Vermont are the last remaining states with two-year gubernatorial terms, in each case with no term limits). The GOP has also won majorities in both chambers of the New Hampshire General Court (the Granite State’s legislature’s formal name) in five of the last six elections, the exception being Trump’s first-term midterm election in 2018. The GOP holds two-thirds of the seats in the state Senate and 55 percent in the state House; there is nothing like that in any other blue or red state.

This could be relevant next year because Democrats have an open U.S. Senate seat in New Hampshire, where Sen. Jeanne Shaheen is not seeking a sixth term. The Democratic nominee will almost certainly be Rep. Chris Pappas, who has represented half of the state in the U.S. House since his first election in 2018. The Republican nominee will likely be former Sen. John Sununu, the one-term incumbent whom Shaheen defeated in 2008. But Sununu must first defeat former Sen. Scott Brown, who won a 2009 special election in Massachusetts but lost his bid for a full term in 2012 to Elizabeth Warren. In 2014 Brown won the GOP nomination for the Senate in New Hampshire, losing to Shaheen by 4 points, in what was an excellent year for the GOP nationally.

All of this is to make two points: 1.) New Hampshire politics is remarkably intertwined; and 2.) given that Sununu's father was a thrice-elected governor and chief of staff to George H.W. Bush, and his brother also served as governor, the Sununu name is not to be underestimated in the Granite State.

If John Sununu can flip the Senate seat state back into the Republican column, we may be making the case here in 2028 that New Hampshire is an eighth purple state.

4 "Big, Beautiful Bill" changes that will reshape care in 2026
Fiscal incentives to expand Medicaid will end. Increased costs for Affordable Care Act (ACA) marketplace enrollees. Medical students will have fewer options to pay student loans. Physicians can expect to see these significant policy changes and others under the One Big Beautiful Bill Act of 2025 (OBBBA) starting in January 2026.

Signed into law in July, the massive budget-reconciliation bill will reduce funding for federal health programs and restrict access to health coverage, said AMA Board Chair David Aizuss, MD, during an AMA Advocacy Insights webinar in November.

As a result, 10 million people could lose health-insurance coverage by 2034, said Dr. Aizuss, citing projections from the Congressional Budget Office (CBO). Meanwhile, if the Affordable Care Act (ACA) "enhanced premium tax credits are not extended past the end of 2025, CBO estimates that the number of uninsured people will increase by more than 14 million in 2034," he added. For more on that issue, read this AMA issue brief (PDF) and this letter from the AMA and 90-plus physician organizations (PDF). (Watch the webinar on demand.)

In the coming years, on the Medicaid side, OBBBA requires more frequent eligibility redeterminations and imposes work requirements for Medicaid expansion enrollees, and restricts how states finance their share of costs and how they pay physicians, health care organizations and other health professionals.

And over the next several years on the marketplace side, OBBBA and marketplace changes “shorten enrollment windows, eliminate automatic re-enrollment and make it harder to get and maintain affordable coverage,” said Annalia Michelman, senior attorney with AMA Advocacy Resource Center. Michelman joined Dr. Aizuss and other AMA policy experts for the webinar to discuss the impact of OBBBA provisions on patients and physicians.

The AMA has created a landing page outlining the changes to Medicaid, the ACA and other key provisions of the One Big Beautiful Bill Act with easily digestible summaries and a one-stop shop for the AMA's press statements and advocacy on the legislation that will have a major impact on the health care landscape for years to come.

Among other resources, the AMA has developed a summary of select OBBBA provisions and when they are being implemented (PDF). Here's more detail from the AMA on four of the big OBBBA-related changes that are set to take effect in 2026. Continue reading

Rust on the Midterm Iron Law? Voters expectations for 2026
By Debra Leiter, Mary Stegmaier, and Michael S. Lewis-Beck of Sabato's Crystal Ball

Midterm elections to the United States Congress are commonly held to be referenda on the performance of the party in the White House. Indeed, they have given rise to an "iron law" in these contests, foretelling "the ruling party would experience a net loss" of seats. With few exceptions, this "law" has been followed. The present political makeup of the federal government, with a Republican president and Republican seat majority in both chambers, strongly implies noteworthy congressional losses for that party in 2026. Thus, the live question becomes, "Will the incumbent party be able to exercise majority control?"

The recent gubernatorial and state-level election results were considered by many to be an early measure of whether the "iron law" might be showing rust. While these results may be more anecdotal than predictive, much political punditry focused on them as the first test for 2026. Though polling indicated some uncertainty in the lead up to these races, and there were reasons to suspect a Republican upset in at least one major gubernatorial contest, we saw instead handy Democratic victories. To some observers, this was a surprise. But when we systematically compare changes in voter expectations earlier in the Trump term to now, we see voters have been updating their expectations for who will win in the 2026 midterm congressional elections. Indeed, from April 2025 to September 2025, voter attitudes shifted.

Our support for this claim comes from potential voters who were interviewed in national scientific surveys fielded by Verasight. The findings on citizen forecasting (CF) suggest voters have studied opinions about which party will control the House and Senate. Furthermore, the forecasts show corrosion of the "iron law." Expectations empirically favor the possibility of a Republican retention of rule. However, those expectations are diminishing. In what follows, we assess two relevant surveys, one from April 2025 and then a later one from September 2025. As we shall see, expectations of a Republican majority have lessened over time. Still, the public gives the incumbent party the nod. By way of conclusion, we assess the accuracy of these predictions. Continue reading

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