The Uninsured Are Spread Throughout Red States, Too

The people who stand to gain the most from the health care law don’t live in just Democratic House districts.

Booklets outlining health insurance options for Californians is seen at a Senior Information & Resource Fair in South Gate, California September 10, 2013.
National Journal
Ronald Brownstein
Oct. 3, 2013, 4:05 p.m.

The big irony be­hind the scorched-earth Re­pub­lic­an of­fens­ive against Pres­id­ent Obama’s health care law is that its ex­pan­sion of cov­er­age to the un­in­sured would be­ne­fit House dis­tricts rep­res­en­ted by Re­pub­lic­ans nearly as much as those rep­res­en­ted by Demo­crats.

In the con­front­a­tion that pre­cip­it­ated this week’s gov­ern­ment shut­down, the near-uni­ver­sal re­frain of Re­pub­lic­an House mem­bers has been that they will “do whatever we can, as much as we can, to pro­tect the people of our dis­tricts from the harm­ful ef­fects of this law,” as Rep. James Lank­ford of Ok­lahoma put it. Re­gard­less of what oth­er pro­vi­sions they con­sider harm­ful, that pos­ture un­avoid­ably means House Re­pub­lic­ans are seek­ing to “pro­tect” a sur­pris­ingly large num­ber of their con­stitu­ents from the right to ob­tain health in­sur­ance with fed­er­al as­sist­ance.

Re­cently re­leased census data show that, on av­er­age, the share of res­id­ents without in­sur­ance is al­most as high in dis­tricts rep­res­en­ted by House Re­pub­lic­ans as in those rep­res­en­ted by Demo­crats. Slightly more Re­pub­lic­ans (107) than Demo­crats (99) rep­res­ent dis­tricts where the un­in­sured per­cent­age is above the na­tion­al av­er­age. Even about half of the 80 con­ser­vat­ive mem­bers whose let­ter hatched the strategy of fund­ing gov­ern­ment only if Obama agreed to de­fund the 2010 Af­ford­able Care Act rep­res­ent dis­tricts where the un­in­sured share ex­ceeds the na­tion­al av­er­age.

This dy­nam­ic un­der­scores how thor­oughly ideo­logy is trump­ing in­terest as Re­pub­lic­ans con­vert the budget and debt show­downs in­to their Ther­mo­pylae for block­ing Obama­care. Be­cause so many House Re­pub­lic­ans rep­res­ent dis­tricts with low cov­er­age levels, these mem­bers are ef­fect­ively seek­ing to pre­vent a sub­stan­tial flow of fed­er­al dol­lars not only to un­in­sured in­di­vidu­als in their com­munit­ies but also to hos­pit­als, doc­tors, and oth­er pro­viders who now are de­liv­er­ing sig­ni­fic­ant levels of un­com­pensated care. “This is really an ideo­lo­gic­al stand — and in Amer­ic­an polit­ics, it [even­tu­ally] tends to be more about eco­nom­ic self-in­terest,” says Robert Blendon, a Har­vard School of Pub­lic Health pro­fess­or who stud­ies pub­lic opin­ion and health care.

The near-con­ver­gence of in­sur­ance avail­ab­il­ity in Demo­crat­ic and Re­pub­lic­an dis­tricts re­flects Amer­ic­an polit­ics’ on­go­ing class re­align­ment. In Con­gress, Demo­crats rep­res­ent an up­stairs-down­stairs co­ali­tion of well-edu­cated, largely white sub­urb­an dis­tricts and heav­ily minor­ity, mostly urb­an­ized lower-in­come dis­tricts. Re­pub­lic­ans rep­res­ent many af­flu­ent places but rely in­creas­ingly on ex­urb­an and rur­al dis­tricts crowded with older and non­col­lege whites, many of whom lack in­sur­ance.

Us­ing data from the Census Bur­eau’s an­nu­al Amer­ic­an Com­munity Sur­vey, re­leased last month, my col­league Mi­chael Mel­lody ranked all 435 dis­tricts by their share of un­in­sured res­id­ents. Heav­ily minor­ity Demo­crat­ic seats dom­in­ated the list’s top rung, but many Re­pub­lic­an dis­tricts in blue-col­lar and rur­al areas placed in the up­per half, too. For in­stance, in the Ap­palachi­an-tinged North Car­o­lina dis­trict of Re­pub­lic­an Rep. Mark Mead­ows, who spear­headed the anti-Obama­care let­ter, nearly 27 per­cent of the work­ing-age pop­u­la­tion (ages 18-64), and about 18 per­cent of the total, lack health in­sur­ance. In Lank­ford’s Ok­lahoma City-based dis­trict, 28 per­cent of work­ing-age people and 20 per­cent of all res­id­ents lack in­sur­ance. “We have or­gan­izers in Waco, Jack­son­ville, and the Cin­cin­nati sub­urbs, and in those places they are do­ing the same things we are do­ing in more-urb­an areas,” says Anne Filipic, pres­id­ent of En­roll Amer­ica, a non­profit group back­ing the law.

The Un­in­sured by Con­gres­sion­al Dis­trict

Con­gres­sion­al dis­tricts with the highest per­cent­age of un­in­sured are in the South­w­est and tend to be in areas with a large His­pan­ic pop­u­la­tion. Mas­sachu­setts has the low­est per­cent­age of un­in­sured due to its state-run health in­sur­ance, which has been in place since 2006.

In­ter­act­ive by BRI­AN Mc­GILL; Source: Census Bur­eau, Amer­ic­an Com­munity Sur­vey

In all, census data show that 15.6 per­cent of res­id­ents in the av­er­age Demo­crat­ic dis­trict are un­in­sured, com­pared with 14.1 per­cent in the av­er­age GOP dis­trict. Like­wise, the share of work­ing-age people who lack in­sur­ance is nearly as high in GOP dis­tricts (19.9 per­cent) as in Demo­crat­ic ones (21.7 per­cent). On both meas­ures, vir­tu­ally identic­al num­bers of Demo­crats and Re­pub­lic­ans rep­res­ent dis­tricts where the un­in­sured share of the pop­u­la­tion ex­ceeds the na­tion­al av­er­age by at least 10 per­cent. And, re­flect­ing the GOP’s grow­ing down­scale tilt, the share of whites without in­sur­ance is ac­tu­ally high­er in the av­er­age Re­pub­lic­an dis­trict (11.1 per­cent) than in the typ­ic­al Demo­crat­ic one (10.2 per­cent).

These num­bers sug­gest that time is the pivot in this struggle. Re­pub­lic­ans un­der­stand­ably feel em­boldened now, while the law faces im­ple­ment­a­tion chal­lenges and broad pub­lic skep­ti­cism. But if Obama holds firm through 2016 — as top ad­visers in­sist he will — the in­cent­ive for more GOP mem­bers could gradu­ally shift from ideo­logy to in­terest. Hos­pit­als, doc­tors, and the un­in­sured them­selves in red dis­tricts may quickly grow ac­cus­tomed to the fed­er­al dol­lars that will flood in to ex­pand cov­er­age after Jan. 1. “Once they are in, it is go­ing to be [al­most] im­possible to take in­sur­ance away from them,” one seni­or White House aide pre­dicts.

Most House Re­pub­lic­ans rep­res­ent such safe dis­tricts that their elect­or­al cal­cu­la­tions prob­ably won’t change much even if more of their voters re­ceive fed­er­ally as­sisted in­sur­ance. But it may be tough­er to ig­nore the in­sti­tu­tion­al de­mands from loc­al med­ic­al in­terests be­ne­fit­ing from ex­pan­ded in­sur­ance cov­er­age that light­ens their load of un­com­pensated care. “You have hos­pit­als, doc­tors, and phar­macists who all say [to them], “˜Take the money,’ “ Blendon notes.

That mount­ing pres­sure is why Blendon joins those who be­lieve that if Re­pub­lic­ans can’t up­root the law soon, they nev­er will. Judging by the fe­ro­city of the con­front­a­tion, the key play­ers on both ends of Pennsylvania Av­en­ue share his con­vic­tion.

The Uninsured by Congressional District

Con­gres­sion­al dis­tricts with the highest per­cent­age of un­in­sured are in the South­w­est and tend to be in areas with a large His­pan­ic pop­u­la­tion. Mas­sachu­setts has the low­est per­cent­age of un­in­sured due to its state-run health in­sur­ance, which has been in place since 2006.

In­ter­act­ive by BRI­AN Mc­GILL; Source: Census Bur­eau, Amer­ic­an Com­munity Sur­vey

In all, census data show that 15.6 per­cent of res­id­ents in the av­er­age Demo­crat­ic dis­trict are un­in­sured, com­pared with 14.1 per­cent in the av­er­age GOP dis­trict. Like­wise, the share of work­ing-age people who lack in­sur­ance is nearly as high in GOP dis­tricts (19.9 per­cent) as in Demo­crat­ic ones (21.7 per­cent). On both meas­ures, vir­tu­ally identic­al num­bers of Demo­crats and Re­pub­lic­ans rep­res­ent dis­tricts where the un­in­sured share of the pop­u­la­tion ex­ceeds the na­tion­al av­er­age by at least 10 per­cent. And, re­flect­ing the GOP’s grow­ing down­scale tilt, the share of whites without in­sur­ance is ac­tu­ally high­er in the av­er­age Re­pub­lic­an dis­trict (11.1 per­cent) than in the typ­ic­al Demo­crat­ic one (10.2 per­cent).

These num­bers sug­gest that time is the pivot in this struggle. Re­pub­lic­ans un­der­stand­ably feel em­boldened now, while the law faces im­ple­ment­a­tion chal­lenges and broad pub­lic skep­ti­cism. But if Obama holds firm through 2016 — as top ad­visers in­sist he will — the in­cent­ive for more GOP mem­bers could gradu­ally shift from ideo­logy to in­terest. Hos­pit­als, doc­tors, and the un­in­sured them­selves in red dis­tricts may quickly grow ac­cus­tomed to the fed­er­al dol­lars that will flood in to ex­pand cov­er­age after Jan. 1. “Once they are in, it is go­ing to be [al­most] im­possible to take in­sur­ance away from them,” one seni­or White House aide pre­dicts.

Most House Re­pub­lic­ans rep­res­ent such safe dis­tricts that their elect­or­al cal­cu­la­tions prob­ably won’t change much even if more of their voters re­ceive fed­er­ally as­sisted in­sur­ance. But it may be tough­er to ig­nore the in­sti­tu­tion­al de­mands from loc­al med­ic­al in­terests be­ne­fit­ing from ex­pan­ded in­sur­ance cov­er­age that light­ens their load of un­com­pensated care. “You have hos­pit­als, doc­tors, and phar­macists who all say [to them], “˜Take the money,’ “ Blendon notes.

That mount­ing pres­sure is why Blendon joins those who be­lieve that if Re­pub­lic­ans can’t up­root the law soon, they nev­er will. Judging by the fe­ro­city of the con­front­a­tion, the key play­ers on both ends of Pennsylvania Av­en­ue share his con­vic­tion.

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