Most of the 2014 midterm election results are in, and one outcome is clear: Democrats in the Senate are about to move into lousy office space.

Other effects are murkier, especially when it comes to the Patient Protection and Affordable Care Act (PPACA) and other federal health policy matters.

The House will have a bigger, stronger, louder Republican majority.

The current Senate Majority leader, Harry Reid, D-Nev., is clearly out. It seems reasonable to assume that Sen. Mitch McConnell, R-Ky., the current Republican leader, will take his place. But Sen. Ted Cruz, R-Texas, a favorite among the members of the Tea Party movement, has refused to endorse McConnell.

Similarly, Sen. Lamar Alexander, R-Tenn., is the highest ranking Republican at the Senate Health, Education, Labor and Pensions (HELP) Committee. It seems reasonable to assume that he’ll be the next Senate leader in charge of PPACA and long-term care (LTC) policy hearings. It’s possible that a populist uprising, or various Republican senators’ own personal preferences, could put someone else in charge of Senate health policy debates.

Sen. Orrin Hatch, R-Utah, might take over from Sen. Ron Wyden, R-Ore., as head of the Senate Finance Committee — but, then again, if populists rule the day, he might not. Hatch faced a Tea Party challenge in Utah. 

Here’s a look at some other possible effects of the new Republican majority in the Senate, and the continuing conflict between the populists in the Tea Party movement and the members of the old guard.

Harry Reid

1. Republicans can pass — only pass — what centrist Democrats really wanted to pass all along.

Republicans who want to repeal PPACA or change it in major ways will continue to face major obstacles. PPACA opponents will need to win over several Democrats to get normal repeal or change bills to the Senate floor, and more Democrats to get bills past presidential vetoes.

But, in this area, fate could intervene. Two of the Blue states in which the governorship passed from Democrats to Republicans — Massachusetts and Maryland — were states in which Democrat-led administrations enthusiastically, loudly supported their public PPACA exchange systems — and then ended up with failed exchange enrollment systems.

The second PPACA public exchange program open enrollment period is set to start Nov. 15 and end Feb. 15.

Big hospital companies — including several based in Lamar Alexander’s home state, Tennessee — are starting to like PPACA. PPACA is increasing the percentage of patients who come in with some kind of health coverage and can pay at least part of their bills. Many insurers also like PPACA, because PPACA has given them the hope of bringing in new enrollees while cutting marketing costs.

If the enrollment period goes reasonably smoothly, moderate Republicans could decide to go along with the hospitals and insurers and warm up to PPACA. Moderate Democrats might have no reason to change their positions on PPACA.

If, however, the second enrollment period is marked by as many technical glitches as the first, some moderate Democrats could have second thoughts about the exchange system, at least in its current configuration.

Still another possibility is that hospitals could emphasize that the part of PPACA making the big difference is Medicaid expansion, not the complicated PPACA exchange system. In that situation, moderate Democrats could cut their losses and work out a compromise that would kill the exchange program but let Medicaid expansion live.

If populists end up with a lot more power in the Senate, that could seriously weaken exchange and Medicaid expansion support. Program supporters might find themselves having to build bipartisan coalitions that shut out the populists in both parties.

After the original version of this story was published, President Obama said at a White House press conference that he wants to see any sincere proposals for improving PPACA and PPACA programs that Republicans in Congress develop. But “on health care,” he said, “there are certainly some lines I’m going to draw. Repeal of the law I won’t sign. Efforts that would take away health care from the 10 million people who now have it and the millions more who are eligible to get it we’re not going to support. In some cases there may be recommendations that Republicans have for changes that would undermine the structure of the law, and I’ll be very honest with them about that and say, look, the law doesn’t work if you pull out that piece or that piece. On the other hand, what I have said is there’s no law that’s ever been passed that is perfect. And given the contentious nature in which it was passed in the first place, there are places where, if I were just drafting a bill on our own, we would have made those changes back then, and certainly as we’ve been implementing, there are some other areas where we think we can do even better.”

Obama said he would not consider approving a bill that would eliminate the PPACA individual health coverage mandate. Many oppose the mandate and question whether it is constitutional. Health insurers have argued that they need an individuial mandate to compensate for the effects of the PPACA provision requiring them to issue major medical coverage without considering individual health status information, and to price the coverage without considering any individual health information other than age and tobacco use.

Obama noted that his 2012 opponent, Mitch Romney, included a mandate provision the Massachusetts exchange system program. “Mitt Romney understood that, if you’re providing health insurance to people through the private marketplace, then you’ve got to make sure that people can’t game the system and just wait until they get sick before they go try to buy health insurance,” Obama said. “You can’t ensure that people with preexisting conditions can get health insurance unless you also say, while you’re healthy, before you need it, you’ve got to get health insurance.”

Image: Sen. Harry Reid (AP photo/J. Scott Applewhite)

U.S. Capitol

2.  Splits between Senate Republicans may be as important as the differences between the Republicans and the Democrats.

One of the well-known, not-very-secret secrets in Washington is that congressional aides who are unknown to the public often play as much of a role in meeting with lobbyists, writing legislation, and negotiating deals as the elected legislators.

A strong split between populist Republican senators and traditional Republican senators could lead to lingering conflicts both at the top and in the ranks of the aides. In some cases, those splits could lead to mysterious difficulties with getting seemingly unbeatable pieces of health policy legislation from a Senate committee to the Senate floor, or from the Senate to the House.

Lamar Alexander

3. Lamar Alexander might be in charge of Senate Health hearings.

Or, he might not be.

Senate committees seem to run in a somewhat more collegial fashion than committees in the House. Under Alexander, the main change at Senate Health hearings may be a decrease in the number of wonky witnesses praising PPACA in vague, glowing terms and an increase in the number of wonky witnesses talking about how PPACA programs are actually working, or not working.

Older couple

4. This could breathe life into cheap long-term care planning incentive proposals.

Moderate Democrastyts in the Senate have generally agreed with Republicans in the Senate the increasing tax incentives and other incentives for consumers to plan and save for their own LTC needs would be nice.

Among Democrats, the most common stated objection has been that the private LTCI market has been too small and too unstable to make much of a difference in overall LTC planning efforts.

The unstated objection may be that the most liberal Democrats were in no mood to help an industry that had gone out of the way to kill Ted Kennedy’s actuarially questionable but noble-minded CLASS Act voluntary LTC benefits program.

Maybe time and the loss of the Senate will get some Democrats in the Senate to look at this subject from a different perspective.

Image: Republican voters are also getting older. (AP Photo/Andy Wong)

Bernie Sanders

5. Bernie Sanders may get more of a chance to shine.

If the Republicans have 52 to 55 seats in the Senate, Republicans who want to get bills passed will want to find ways to cross party lines to build coalitions with moderate Democrats.

Democrats who still want to be players will want to reach across the aisle to work with Republicans.

Socialist independents who know they are unlikely to get many bills or amendments they like passed by being meek may feel freer than ever to speak their minds and raise a ruckus.

See also: Vermont working on single-payer system

Tomorrow, see our list of 5 more ways the Republican Congress could reshape the health policy debate.