On the first day of the 18th Congress of the Philippines, Cayetano was elected House Speaker after gaining 266 votes against Manila 6th District Representative Benny Abante Jr., who garnered 28 votes. Cayetano became the 22nd Speaker of the House of Representatives of the Republic of the Philippines on July 22, 2019. He was nominated by Representatives Lord Allan Jay Velasco, Martin Romualdez and Presidential Son Rep. Paolo "Pulong" Duterte. These three representatives also announced their intention to run for speaker, but President Rodrigo Duterte gave his endorsement to Cayetano.