Many of the House members in both parties who are most opposed to the health care reform legislation moving toward a historic vote represent districts where the share of residents without insurance exceeds the national average, often by substantial amounts, according to recently released census data.
The parties agree that the Democratic-crafted reform bill now being stitched together from legislation passed by three House committees will face virtually uniform opposition from the chamber's Republicans. And the legislation is also facing skepticism from many moderate-to-conservative Democratic "Blue Dogs," especially those from districts carried by John McCain in last year's presidential contest.
Yet many House members from both groups represent districts with an elevated number of people who lack health insurance.
That dynamic creates the likelihood of a deeply ironic result: If health care reform passes, many of the districts that benefit most from the federal subsidies to expand access to coverage will be those represented by members who voted against the bill. "There's no question that is the case," said Robert Blendon, a professor of health policy at the Harvard University School of Public Health.
In all, the share of uninsured people is slightly greater in Democratic- than Republican-held House seats, a National Journal analysis of the census data found. But that cumulative difference is modest: On average, 15.2 percent of people lack insurance in districts represented by Democrats, compared with 14.7 percent in districts represented by Republicans.
Another pattern may be more unexpected. House Republicans are slightly more likely than their Democratic counterparts to represent districts where the share of people without health insurance exceeds the national average of 15 percent. Fully 47 percent of House Republicans (84 of 178) represent districts where the proportion of the uninsured exceeds that average. Among Democrats, 43 percent (111 of 257) represent districts in which the share of the uninsured exceeds the national average.
These figures are drawn from the Census Bureau's 2008 American Community Survey, which produced a slightly different overall rate of insurance coverage for the nation than the bureau's annual report on health insurance. That report uses another survey (the Annual Social and Economic Supplement to the Current Population Survey) to calculate its figures. The annual report placed the share of Americans without health insurance at 15.4 percent; the ACS put it at 15 percent. This is the first year that the American Community Survey has included questions about access to health insurance in its report, which provides results down to the congressional district level; the census released the data in late September.
The American Community Survey results suggest that two types of districts generally suffer the most from lack of access to insurance: low-income, often heavily minority districts, and largely rural or small-town white districts, especially in the South. Most of the Democratic districts with the highest proportion of uninsured fall into the former category; the heavily uninsured Republican districts split between the two groups. The decisive votes on health care may come from the moderate Blue Dog Democrats representing areas that are demographically and ideologically similar to the rural Republican districts with big numbers of uninsured.
Blendon said he's not surprised that many of the bill's staunchest opponents -- both Republican and Democratic -- represent districts that might benefit most directly from the effort to expand coverage. Political scientists, he notes, have consistently found that state spending on social welfare has correlated more closely with political attitudes than with the degree of need; conservative-leaning but poor states have tended to spend much less on social programs than liberal-leaning states where the absolute need may be less. "It is not need that determines votes or expenditures," Blendon says. "It's ideology."
Twenty-five House Republicans represent districts where at least 20 percent of residents lack health insurance. At the top of the list is National Republican Congressional Committee Chairman Pete Sessions of Texas; just under one-third of the residents in his heavily minority North Dallas district lack insurance. Right behind Sessions are three Cuban-American Republicans in South Florida: brothers Mario and Lincoln Diaz-Balart and Ileana Ros-Lehtinen. Five other Texas Republicans, and Rep. Devin Nunes from California's Central Valley, fill out the list of the 10 Republicans representing districts with the largest proportion of uninsured.
Jennifer Crider, a spokeswoman for the Democratic Congressional Campaign Committee, argues that Republicans from highly uninsured districts who oppose health care reform will "open themselves to some political peril" by seeming to favor ideology over local needs. "If you make a political vote without regard to what's best for your district, there will be a price to pay for that," she contends.
Republicans from these areas appear ready to argue that they support reform to expand access to insurance -- just not the reforms that Democrats are offering. Asked about the many residents without insurance in his district, Sessions said in an e-mail that "the need for reform is clear" and declared that he supported "tax incentives for health coverage, greater pooling mechanisms, and tort reform to reduce costs." But, he added, the Democratic proposals amount to a "government takeover" that would result "in increased costs, fewer choices, higher taxes, deeper deficits, and interference in the patient/doctor relationship."
Ros-Lehtinen raised similar arguments in an e-mail statement. "I'm mindful of the need for real health care reform in my severely under- and uninsured congressional district," she said. "However, the costly bills before the Congress are not the answer."
Another 59 Republicans (33 percent of the caucus) represent districts where between 15 percent and 20 percent of the population is uninsured. The rest represent districts where the share of uninsured ranges between 10 percent and 15 percent (32 percent of the members) or below 10 percent (21 percent).
Democrats expect virtually -- and perhaps literally -- none of the Republicans from any of these categories to support the Democratic legislation.
Among Democrats, the party leadership's challenge revolves largely around the 49 members representing districts carried last year by McCain. Those McCain-district Democrats cast a majority of the dissenting votes in the party when the House narrowly passed climate-change legislation in June, and many are balking again at supporting health care reform. (See "Freshmen, Both Seen and Heard," p. 32.) Of the 11 Democrats who have already voted against the various reform bills in committee, six represented districts that McCain carried last year.
Overall, the analysis found that 14.7 percent of the population in the McCain-Democrat districts lack health insurance. That's slightly below the 15.4 percent average in the 208 Democratic-held districts that President Obama carried last fall. The difference reflects the fact that Obama won the minority-centered districts that often contain the largest numbers of uninsured: Obama won all but two of the 20 congressional districts with the largest proportion of uninsured.
But the McCain Democrats are as likely as the Obama Democrats to represent districts where the proportion of people without insurance exceeds the national average. The share of the uninsured is greater than the national average in 21 of the 49 McCain-Democrat districts, or just under 43 percent. The proportion is about the same in the Obama-carried Democratic districts -- 90 of 208, just over 43 percent.
However, senior Democratic vote-counters now believe about half of those 21 McCain-district Democrats with the most uninsured are likely to oppose the final legislation. Party vote-counters expect opposition from, among others, Rep. Dan Boren, whose Oklahoma district ranks highest for the uninsured among the McCain Democrats at just below 25 percent, as well as Ann Kirkpatrick of Arizona, Harry Teague of New Mexico, Gene Taylor of Mississippi, Jim Marshall of Georgia, and Mike Ross of Arkansas, all of whom represent districts where about one-fifth or more of the population lacks insurance.
Boren's office did not respond to a request for comment about his position. In an interview, Ross said he supported several of Obama's key principles. "We need to make insurance affordable, provide subsidies to the working poor, increase the number of people living near poverty that quality for Medicaid... and reform the health insurance industry," he said. But Ross reiterated that he would not vote for a reform bill that included a public competitor to private insurance companies. Kirkpatrick's office said that she has not decided how to vote.
Democratic vote-counters believe another eight of the 21 McCain Democrats in the most heavily uninsured districts are likely to vote for the bill -- including John Salazar of Colorado, Chet Edwards of Texas, and Nick Rahall of West Virginia -- with the remaining three uncertain.
In a measure of the increasing Democratic success in upscale communities, slightly more than one-fifth of the party's House caucus represents districts where only 10 percent or less of the population lacks health insurance, almost exactly the same proportion as among House Republicans. Indeed, looking at the House through the lens of access to health insurance vividly captures the bifurcated upstairs-downstairs nature of the modern Democratic coalition: As Dennis Cauchon of USA Today recently observed, Democrats hold all 10 of the seats with the largest proportion of uninsured and all 10 with the smallest.
Research Associate Cameron Joseph contributed to this article.
This article appears in the October 24, 2009, edition of National Journal Magazine Contents.