Despite repeatedly failing to advance legislation through the Senate, Republicans in Congress have not abandoned their goal of repealing and replacing the Affordable Care Act (ACA). The latest attempt at repeal in the form of the Graham-Cassidy bill would have established a per capita cap on federal Medicaid financing, eliminated the individual mandate, and undermined protections for older adults and people with preexisting conditions, by allowing states to opt out of key ACA insurance regulations. It would also have eliminated funding for the ACA's Marketplace premium and cost-sharing subsidies and Medicaid expansion, and redirected some of that funding toward block grants to states.
One puzzling aspect of this and previous repeal efforts is that they nearly succeeded in spite of widespread public support for the core elements of the ACA that would have been overturned. Although almost 80 percent of nonelderly adults favor keeping the Medicaid expansion and nearly 70 percent favor keeping the premium subsidies, previous legislation eliminating or weakening these provisions passed the House by a vote of 217–213 (with House votes by district shown in Exhibit 1) and fell just a few votes short of passing the Senate. ACA protections for people with preexisting conditions—including guaranteed issue, community rating, and essential health benefits—are even more popular, eliciting support of 80 percent to 90 percent of nonelderly adults, and age rating limits are supported by three-quarters of adults.
Exhibit 1: US House Of Representatives' Votes For The American Health Care Act, By Congressional District
Source: GovTrack.us. Note: AHCA is American Health Care Act.
A possible explanation for the perseverance toward repeal despite its unpopularity is that residents in districts and states where members of Congress voted for repeal may exhibit less support for key ACA provisions compared to those living in districts and states where members voted against repeal. If favorability toward these provisions varies widely across politically polarized Congressional districts and states, voting patterns in Congress may simply reflect legislators' responsiveness to the preferences of their constituents. In contrast, if favorability toward ACA provisions is high across districts and states, it would indicate that the push for repeal is motivated by factors beyond constituent demands.
Most Nonelderly Adults Support Keeping Core ACA Provisions In Districts Where Members Of The House Voted For Repeal
To understand the link between congressional votes and public opinion on ACA repeal, we used data from the Urban Institute's March 2017 Health Reform Monitoring Survey to examine public support for keeping or repealing core ACA provisions among a sample of more than 9,500 nonelderly adults—and the potential impact of repeal on coverage—based on how their member of the US House of Representatives voted for the American Health Care Act (AHCA) last May and how their senators voted for the Better Care Reconciliation Act (BCRA) and Obamacare Repeal and Reconciliation Act (ORRA) last July. Senators voted on a third repeal bill, the Health Care Freedom Act, that would have eliminated the individual mandate without directly targeting other core coverage provisions described in the survey.
We found that although support was somewhat lower in House districts where representatives voted for the AHCA, 75.2 percent of adults in these districts supported keeping the Medicaid expansion and 64.3 percent of them supported keeping the premium subsidies (Exhibit 2). In districts where representatives voted against AHCA, support was 81.0 percent for Medicaid expansion and 72.6 percent for the premium subsidies. There were no differences by districts' House votes in support for the ACA's guaranteed issue and community rating provisions, and only slightly higher support for essential health benefit requirements and age rating limits in districts where representatives voted against the AHCA.
Exhibit 2: Support For Keeping ACA Provisions As Of March 2017 Among Adults Ages 18–64, By US House Of Representatives' Votes For The American Health Care Act
Sources: Health Reform Monitoring Survey, quarter 1, 2017; GovTrack.us. Notes: ACA is Affordable Care Act. AHCA is American Health Care Act. */**/*** Estimate differs significantly from adults in districts where representative voted for the AHCA at the 0.10/0.05/0.01 level, using two-tailed tests.
Little Or No Variation Across States In Support For Core ACA Provisions
Support for Medicaid expansion did not vary across states. In states where at least one senator voted for either the BCRA or the ORRA, 77.5 percent of adults supported keeping the Medicaid expansion, which is not significantly different from the 79.1 percent supporting Medicaid expansion in states where both senators voted against both repeal bills (Exhibit 3). Support for keeping premium subsidies was somewhat lower in states where a senator voted for repeal (65.7 percent versus 71.9 percent). In states where both senators voted against both repeal bills, adults were only 2.2 percentage points more likely to support guaranteed issue, 2.0 percentage points more likely to support community rating, and 4.3 percentage points more likely to support age rating limits relative to adults in states where at least one senator voted for repeal. Support for essential health benefits was similar in each state group.
Exhibit 3: Support For Keeping ACA Provisions As Of March 2017 Among Adults Ages 18–64, By US Senators' Votes For The BCRA And The ORRA
Sources: Health Reform Monitoring Survey, quarter 1, 2017; GovTrack.us. Notes: ACA is Affordable Care Act. BCRA is Better Care Reconciliation Act. ORRA is Obamacare Repeal and Reconciliation Act. */**/*** Estimate differs significantly from adults in states where at least one senator voted for the BCRA or the ORRA at the 0.10/0.05/0.01 level, using two-tailed tests.
It is possible that members of Congress are more responsive to certain segments of their districts and states, including those individuals who are most likely to vote or those who participate in primary elections. However, we found that in districts where representatives voted for the AHCA, support for most core ACA provisions was high among those who either self-identify as Republicans or lean toward the Republican Party platform, including those who refer to themselves as "strong" Republicans (Exhibit 4). Majorities of both groups supported keeping the Medicaid expansion and consumer protections. About half of those who identify as Republican or lean Republican and 41 percent of strong Republicans supported keeping the premium subsidies. Similar patterns were found among Republicans in states where at least one senator voted for repeal. We also found widespread support across all districts and states among groups with high voter participation rates, including those ages 50–64 and those with high levels of education and income (data not shown).
Exhibit 4: Support For Keeping ACA Provisions As Of March 2017 Among Republicans Ages 18–64 In Districts And States Where Members Of Congress Voted For Repeal
Sources: Health Reform Monitoring Survey, quarter 1, 2017; GovTrack.us. Notes: ACA is Affordable Care Act. AHCA is American Health Care Act. BCRA is Better Care Reconciliation Act. ORRA is Obamacare Repeal and Reconciliation Act.
Repeal Would Jeopardize Coverage And Benefits Of Adults Across House Districts
Adults with Marketplace coverage or Medicaid—including the Medicaid expansion population and those enrolled in Medicaid under pre-ACA eligibility rules—could be affected by repeal of Medicaid expansion, benefit cuts resulting from the establishment of per capita caps on Medicaid funding, elimination of premium subsidies, and/or loss of consumer protections. The share of adults with these types of coverage is larger in House districts where representatives voted against the AHCA. However, these changes would still affect many adults in districts where representatives voted for the AHCA. About 1 in 5 adults (19.5 percent) in House districts where members voted against repeal were enrolled in Medicaid or Marketplace coverage, compared to about 1 in 6 adults (16.3 percent) in House districts where members voted for repeal (Exhibit 5). These differences were driven by the higher Medicaid enrollment in states expanding Medicaid, where representatives were more likely to vote against the AHCA; there were no significant differences in Marketplace enrollment. An additional 3 percent of adults were enrolled in non-Marketplace nongroup coverage both in districts where representatives voted for the AHCA and in districts where they did not. These adults are not eligible for premium subsidies but could lose protections against discrimination by age or health status. Nearly two-thirds (63.3 percent) of adults with Marketplace plans with a premium reported that their premium was subsidized (data not shown). Another 18.5 percent of Marketplace enrollees with a premium did not know whether they received a subsidy, indicating that the 63.3 percent reporting a subsidy represents a lower bound on the share with subsidized coverage.
Exhibit 5: Share Of Adults Ages 18–64 Enrolled In Medicaid And Marketplace Coverage As Of March 2017, By Representatives' And Senators' Votes For Repeal
Sources: Health Reform Monitoring Survey, quarter 1, 2017; GovTrack.us. Notes: ACA is Affordable Care Act. AHCA is American Health Care Act. BCRA is Better Care Reconciliation Act. ORRA is Obamacare Repeal and Reconciliation Act. */**/*** Estimate differs significantly from adults in districts or states where representatives/senators voted for repeal at the 0.10/0.05/0.01 level, using two-tailed tests.
In States Where Senators Voted For Repeal, A Larger Share Of The Population Would Be At Risk Of Losing Marketplace Coverage
Although adults were more likely to be enrolled in Medicaid in states where both senators voted against both repeal bills (which were generally Medicaid expansion states) than in states where at least one senator voted for repeal (14.8 percent versus 10.7 percent), Marketplace coverage was slightly higher in states where a senator voted for repeal (6.0 percent versus 4.6 percent) (Exhibit 5). The difference in Marketplace enrollment is likely due in part to eligibility for Marketplace subsidies for adults with incomes between 100 percent and 138 percent of the federal poverty level in states that did not expand Medicaid.
Limitations To The Analysis
One limitation to this analysis is that our sample is only adults ages 18–64, and there may be more variation in public opinion toward the ACA across districts and states among the elderly population. However, we found similar patterns across states and districts when we limited our sample to adults ages 60–64, suggesting levels of support across districts and states may be consistent for older age groups as well. In addition, public opinion toward the ACA has changed since March 2017, although most polls have shown a rise in support for the ACA, and growing opposition to repeal legislation would suggest an even larger gap between congressional efforts and constituent preferences.
Without A Strategy For Protecting Coverage, Repealing Core ACA Provisions Threatens Recent Gains In Health Care Access
These findings suggest that congressional votes to repeal the ACA's core financial assistance provisions and consumer protections are not aligned with the preferences of constituents. Moreover, the potential loss of coverage and benefits from repealing these provisions and transforming Medicaid financing is high in both areas where members of Congress are pursuing repeal and areas where members have opposed repeal. Public opinion and concern for those who would be harmed may have helped derail repeal efforts thus far, but Republicans have come close to securing a legislative majority that is not deterred by these factors. If legislation modeled on Graham-Cassidy or previous repeal bills succeeds without a clear strategy for sustaining coverage, it is likely to reverse the recent gains in health care access and affordability in districts and states across the country.
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