As the Affordable Care Act, or ACA, repeal bill comes up for a vote, members of Congress face a choice on whether or not to move forward with stripping coverage from their constituents. While the Congressional Budget Office, or CBO, has not yet released its score for the current version of legislation, it found an earlier version of the bill would have resulted in 24 million fewer nonelderly Americans with health insurance by 2026.
The House bill’s effects are staggering, even at a local level. Within a decade, on average, an additional 55,000 more individuals in each congressional district, or nearly 8 percent of each district’s entire population today, would lack coverage. In the table below, we provide estimates of coverage losses for all 435 congressional districts of the 115th Congress as well as the District of Columbia.
For each district, we provide an estimated number of people who would be uninsured under the House bill instead of having health insurance through the workplace, Medicaid, and the exchanges and other private coverage. Our numbers reflect that states that have expanded Medicaid to low-income adults under the ACA would face drastic cuts to federal matching funds for the program starting in 2020 and that expansion would no longer be a viable option by 2026 for states that have not already done so.
David Cutler is the Otto Eckstein Professor of Applied Economics at Harvard University. Emily Gee is a Health Economist at the Center for American Progress.
To download the table by congressional district, click here.
Our estimates of coverage reductions by congressional district come from combining the CBO’s projected national net effects on coverage with state and local data from the Kaiser Family Foundation, the American Community Survey from the U.S. Census, and administrative data from the Centers for Medicare & Medicaid Services, or CMS.
Florida, North Carolina, and Virginia redrew their district boundaries prior to the 2016 elections. While the rest of our data uses Census estimates corresponding to congressional districts for the 114th Congress, we instead used county-level data from the 2015 5-year American Community Survey to determine the geographic distribution of the population by insurance type in these three states. We matched county data to congressional districts for the 115th Congress using a geographic crosswalk file provided by the Kaiser Family Foundation.
Our calculation of reductions in employer-sponsored insurance were most straightforward. The CBO projects a net 7 million fewer people will obtain insurance through the workplace by 2026, and we assigned each district a share proportional to its number of nonelderly people with employer-sponsored coverage in the 2015 American Community Survey.
Estimating reductions in Medicaid by district required more assumptions. The CBO projects that a total 14 million fewer people would have Medicaid coverage by 2026 under the House bill: 5 million fewer would be covered by additional Medicaid expansion in new states, and 9 million fewer would have Medicaid coverage in current expansion states and among pre-ACA eligibility groups in all states. The CBO projects that, under the ACA, additional Medicaid expansion would increase the proportion of the newly eligible population residing in expansion states from 50 percent to 80 percent by 2026. It projects that, under the House bill, just 30 percent of the newly eligible population would be in expansion states. Extrapolating from the CBO’s numbers, we estimate the bill results in a Medicaid coverage reduction of 3.3 million enrollees in current expansion states by 2026.
We then assume the remaining 5.7 million people who would lose Medicaid coverage are from the program’s pre-ACA eligibility categories: low-income adults, low-income children, the aged, and disabled individuals. We used enrollment tables published by MACPAC to determine total state enrollment and each eligibility category’s share of the total, and we assumed that only some of the disabled were nonelderly. We then divided state totals among districts according to each’s Medicaid enrollment in the American Community Survey. Because each of the major nonexpansion categories is subject to per capita caps under the bill, we reduced enrollment in all by the same percentage.
Because we do not know which individual states would participate in Medicaid expansion in 2026 in either scenario, our corrected estimates give nonexpansion states the average effect of forgone expansion and all expansion states the average effect of rolling back eligibility. We divided the 5 million enrollment reduction due to forgone expansion among nonexpansion states’ districts proportionally by the number of low-income uninsured. We made each expansion state’s share of that 3.3 million proportional to its Medicaid expansion enrollment in its most recent CMS report and then allocated state totals to districts proportional to the increase in nonelderly adult enrollment between 2013 and 2015. For Louisiana, which recently expanded Medicaid, we took our statewide total from state data and allocated to districts by the number of low-income uninsured adults.
Medicaid covers seniors who qualify as aged or disabled. Although the CBO did not specify the Medicaid coverage reduction that would occur among seniors under per capita caps, applying to elderly enrollees the same percentage reduction we calculated for nonexpansion Medicaid enrollees implies that 900,000 could lose Medicaid.
Lastly, our estimates of the reduction in exchange, the Basic Health Plan, and other nongroup coverage are proportional to the Kaiser Family Foundation’s estimates of exchange enrollment by congressional district. The House bill reduces enrollment in nongroup coverage, including the exchanges, by 2 million relative to the ACA. To apportion this coverage loss among congressional districts, we assumed that the coverage losses would be largest in areas with higher ACA exchange enrollment and in states where we estimate the average cost per enrollee would increase most under the House plan. The CBO projects that 1 million people with “other coverage” types, including BHP, will be uninsured as of 2026. We assigned the 1 million reduction to the two states that currently offer BHP: Minnesota and New York.