Impact of ACA Repeal on the 1st Congressional District of Massachusetts

455 Pages·2017·3.46 MB·English

by  Esther Grambs

U.S. House of Representatives
Committee on Energy and Commerce
Committee on Oversight and
Government Reform

Democratic Staff Memo

True Costs of Repeal: Republican Plans to Repeal the Affordable
Care Act Will Harm Every Congressional District

March 2017
I. EXECUTIVE SUMMARY

As a direct result of the Patient Protection and Affordable Care Act (ACA), more than 20
million Americans have gained access to affordable and high quality health insurance, and the
country’s uninsured rate has reached an historic low. The ACA’s historic coverage gains were
achieved by expanding Medicaid and creating online Marketplaces for consumers to purchase
insurance with financial assistance in the form of premium tax credits and cost-sharing
reductions.1

Since 2010, congressional Republicans have taken endless actions to sabotage the ACA
through funding cuts, legislative changes, and legal challenges. Republicans in Congress are
now threatening to repeal the ACA through a process known as budget reconciliation. Repealing
the ACA and reversing the Medicaid expansion would harm lower and middle class Americans
in every congressional district. Repeal of the ACA’s market reforms and Republican proposals
to tax employer-based coverage would harm Americans in every congressional district who
receive health insurance through their employer.

To examine the impact of potential ACA repeal on each of the 435 congressional districts
and the District of Columbia, the Democratic staff of the Committees analyzed health insurance
data collected from sources including the Census Bureau’s American Community Survey (ACS)
and Small Area Health Insurance Estimates (SAHIE).

The analysis found: (1) all congressional districts and the District of Columbia have seen
reductions in their uninsured rates since the ACA was implemented, with an average reduction of
5.4 percentage points; (2) on average, 396,200 individuals with employer-sponsored insurance in
each congressional district are at risk of losing important consumer protections if the ACA is
repealed, and could be subject to a new tax on employer-sponsored insurance that would amount
to the largest middle-class tax hike in the last 50 years; and (3) on average, 360,200 individuals
in each congressional district stand to lose access to free preventive care if the ACA is repealed.

Staff conducted additional analyses to examine the potential impact of repeal on
Republican congressional districts, whose representatives have been advocating strongly for
ACA repeal. The analysis found: (1) 79 Republican congressional districts have seen greater
than average reductions their uninsured rates; (2) 99 Republican congressional districts have seen
greater than average Marketplace enrollment; and (3) 85 Republican congressional districts have
seen greater than average gains in Medicaid enrollment.

Nearly 80 Republican congressional districts have seen greater than average declines in
their uninsured rates. In Rep. David Valado’s (R-CA) district, the uninsured rate declined by
13.1 percentage points—more than twice the average. Below are the ten Republican
congressional districts with the largest reductions in the uninsured rate since the ACA was

1 Approximately 2.3 million young adults under 26 gained coverage as a result of an
ACA reform that requires insurers to allow young adults to stay on their parents’ insurance
policies, but this analysis does not examine the impact of this provision at the congressional
district level.
2
implemented.

Table 1: Top Ten Republican Districts, By Decline in Uninsured Rate

District Representative Uninsured rate, Uninsured rate, Change in Uninsured
2012 2015 Rate
CA-21 David Valadao 25.4 12.2 13.1
FL-27* Ileana Ros-Lehtinen 29.1 16.4 12.7
KY-5 Hal Rogers 17.4 5.7 11.8
CA-8 Paul Cook 18.9 7.7 11.2
NV-2 Mark Amodei 20.2 9.8 10.4
FL-26* Carlos Curbelo 28.8 18.5 10.3
CA-10 Jeff Denham 16.2 6.3 9.9
CA-23 Kevin McCarthy 15.7 5.9 9.8
WV-1 David McKinley 14.7 4.9 9.8
CA-39 Ed Royce 17.1 7.4 9.7
*Denotes state that did not expand Medicaid

Republican congressional districts have also seen significant Marketplace enrollment,
which contributed to declines in the uninsured rates even in states that chose not to expand
Medicaid. Rep. Ileana Ros-Lehtinen’s (R-FL) district had nearly 100,000 people enrolled in
Marketplace coverage. In total, 99 Republican congressional districts saw greater than average
Marketplace enrollment. Below are the ten Republican congressional districts with the highest
Marketplace enrollment levels.

Table 2: Top Ten Republican Districts, By Marketplace Enrollment

District Representative Marketplace Enrollment
FL-27 Ileana Ros-Lehtinen 96,300
FL-26 Carlos Curbelo 92,500
FL-25 Mario Diaz-Balart 83,100
FL-18 Brian Mast 60,000
GA-7 Rob Woodall 53,600
MT Ryan Zinke* 51,800
FL-19 Francis Rooney 50,300
FL-6 Ron DeSantis 48,800
ID-1 Raul Labrador 47,200
ID-2 Mike Simpson 47,100
*Seat became vacant as of March 1, 2017

Republican congressional districts have also seen dramatic gains in Medicaid coverage as
a result of the ACA’s Medicaid expansion. More than 80 Republican congressional districts saw
greater than average enrollment through the Medicaid expansion. Rep. Greg Walden (R-OR)
had the largest Medicaid expansion enrollment of any Republican congressional district, with
nearly 130,000 of his constituents enrolling in Medicaid through the expansion. Below are the
ten Republican districts with the highest Medicaid expansion enrollment levels.

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Table 3: Top Ten Republican Districts, By Medicaid Expansion Enrollment

District Representative Medicaid Expansion Enrollment
OR-2 Greg Walden 129,200
CA-21 David Valadao 115,600
KY-5 Hal Rogers 104,600
WA-4 Dan Newhouse 87,400
NY-23 Tom Reed 86,100
NM-2 Steve Pearce 85,900
CA-8 Paul Cook 85,600
CA-22 Devin Nunes 82,800
NY-22 Claudia Tenney 82,300
NY-11 Dan Donovan 78,800

These Republican congressional districts will be the most negatively impacted by their
representatives’ plans to repeal the ACA.

The analysis reveals that repeal of the ACA would endanger coverage for newly insured
Americans, millions of whom live in Republican congressional districts. Despite the fact that
significant numbers of their own constituents are currently enjoying the law’s many benefits,
House Republicans continue to pursue their extreme, ideological agenda of repealing the ACA at
any cost.

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II. BACKGROUND

A. The ACA has Expanded Access to Coverage, Improved the Quality of
Coverage, and Reduced Health Care Spending

The ACA has expanded affordable, quality health insurance to approximately 20 million
Americans—many for the first time in their lives.2 As a direct result of the ACA, 3.4 million
children have now gained coverage, as have 3.6 million Americans whose pre-existing health
conditions previously prevented them from accessing affordable insurance.3 An additional 2.3
million young adults have been able to stay on a parent’s insurance plan, and 14 million people
are now covered through the ACA’s Medicaid expansion.4 The ACA has also made health
insurance more affordable for approximately 9.4 million Americans who receive financial
assistance to purchase insurance through the ACA Marketplaces in the form of advance premium
tax credits and the 6.4 million Americans who receive financial assistance in the form of cost-
sharing reductions.5 The country’s uninsured rate is at an historic low—8.6 percent in 2016, as
compared with approximately 16 percent in 2010, before the ACA was implemented.6

The ACA put an end to the discriminatory and abusive insurance practices that were
rampant before the law was enacted. Prior to the ACA, 105 million Americans—including 70
million Americans with employer-sponsored insurance—faced annual or lifetime dollar limits on

2 National Center for Health Statistics, Centers for Disease Control and Prevention,
Department of Health and Human Services, Health Insurance Coverage: Early Release of
Estimates from the National Health Interview Survey, January-March 2016 (Sept. 2016) (online
at www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf).
3 House Committees on Oversight and Government Reform and Energy and Commerce,
Democratic Staff, Oversight and Energy & Commerce Dems Release State Fact Sheets on
Impact of GOP Assault on ACA (Jan. 5, 2017) (online at democrats-
oversight.house.gov/news/press-releases/oversight-and-energy-commerce-dems-release-state-
fact-sheets-on-impact-of-gop); Office of the Assistant Secretary for Planning and Evaluation,
Department of Health and Human Services, Health Insurance Coverage for Americans with Pre
Existing Conditions: The Impact of the Affordable Care Act (Jan. 5, 2017) (online at
aspe.hhs.gov/system/files/pdf/255396/Pre-ExistingConditions.pdf).
4 House Committees on Oversight and Government Reform and Energy and Commerce,
Democratic Staff, Oversight and Energy & Commerce Dems Release State Fact Sheets on
Impact of GOP Assault on ACA (Jan. 5, 2017).
5 Centers for Medicare and Medicaid Services, Department of Health and Human
Services, March 31, 2016 Effectuated Enrollment Snapshot (June 30, 2016) (online at
www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-
30.html) (accessed Jan. 3, 2017).
6 National Center for Health Statistics, Centers for Disease Control and Prevention,
Department of Health and Human Services, Health Insurance Coverage: Early Release of
Estimates from the National Health Interview Survey, January-March 2016 (Sept. 2016) (online
at www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf).
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their coverage.7 As a result of the ACA, insurance plans can no longer place annual or lifetime
limits on care. Prior to the ACA, women who lived in states that allowed gender rating paid
from 10 percent to 57 percent more than men for their health insurance, simply for being a
woman.8 The ACA put an end to this practice. Prior to the ACA, 52.2 million Americans had
pre-existing medical conditions that meant they could be charged more for coverage, face
exclusions or limitations on their care, have their coverage rescinded, or be denied health
insurance altogether.9 Insurance companies can no longer discriminate on the basis of health
status, as a direct result of the ACA.

The ACA has improved the quality of health insurance for all Americans, including
those who receive insurance through their employer. Approximately 137.7 million Americans
with private insurance—including employer-sponsored insurance—receive free preventive
services, such as cholesterol screenings, mammograms, and flu shots.10 Seniors have also
benefited from this reform. As a result of the ACA, approximately 26.5 million seniors enrolled
in Medicare Part B received free wellness visits and preventive services in 2015.11 The ACA
also improved the quality of coverage in the individual and small group markets. All insurance
plans sold in these markets must now cover ten categories of Essential Health Benefits, including
prescription drugs, mental health services, emergency services, and pediatric care.12

In addition to expanding access and improving the quality of coverage, the ACA has
helped millions of Americans save money by slowing premium growth. Employer-sponsored

7 Office of the Assistant Secretary for Planning and Evaluation, Department of Health
and Human Services, ASPE Issue Brief: Under the Affordable Care Act, 105 Million Americans
No Longer Face Lifetime Limits on Health Benefits (Mar. 2012) (online at aspe.hhs.gov/basic-
report/under-affordable-care-act-105-million-americans-no-longer-face-lifetime-limits-health-
benefits).
8 National Women’s Law Center, Turning to Fairness (Mar. 2012) (online at
www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf).
9 Kaiser Family Foundation, Pre-Existing Conditions and Medical Underwriting in the
Individual Insurance Market Prior to the ACA (Dec. 12, 2016) (online at kff.org/health-
reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-
insurance-market-prior-to-the-aca).
10 Department of Health and Human Services, Office of the Assistant Secretary for
Planning and Evaluation, Compilation of State Data on the Affordable Care Act (Dec. 2016)
(online at aspe.hhs.gov/compilation-state-data-affordable-care-act ).
11 Department of Health and Human Services, Centers for Medicare and Medicaid
Services, Beneficiaries Utilizing Free Preventive Services by State, 2015 (online at
https://downloads.cms.gov/files/Beneficiaries%20Utilizing%20Free%20Preventive%20Services
%20by%20State%20YTD%202015.pdf) (accessed Jan. 3, 2017).
12 Center for Consumer Information and Insurance Oversight, Centers for Medicare and
Medicaid Services, Department of Health and Human Services, Information on Essential Health
Benefits (EHB) Benchmark Plans (online at www.cms.gov/cciio/resources/data-
resources/ehb.html) (accessed Feb. 22, 2017).
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insurance premiums have increased at an annual rate of approximately 5 percent since the ACA
was implemented, as compared to 7.9 percent before the ACA. As a result, the average family
paid about $3,600 less for employer-sponsored insurance in 2016 than it would have paid had the
ACA not been enacted.13 Premiums in the individual insurance market have also grown 12
percent to 20 percent more slowly than projected before the ACA was passed.14

B. Repealing the ACA Would Harm All Americans

President Trump and congressional Republicans’ plan to repeal the ACA will have
devastating effects for all Americans. Eliminating premium tax credits and cost-sharing
reductions will likely make coverage unaffordable for many of the millions of Americans who
received financial assistance to purchase insurance through the ACA Marketplaces in 2016.
Similarly, eliminating the Medicaid expansion will likely result in coverage becoming
unattainable or unaffordable to the more than 14 million Americans who have coverage through
the ACA’s historic Medicaid expansion. Republican proposals to tax employer-based health
coverage could destabilize employer-based coverage and raise taxes on individuals who have
health insurance through their employer.

A recent analysis issued by the Congressional Budget Office (CBO) and the Joint
Committee on Taxation (JCT) estimates that 18 million Americans would lose their health
insurance in just the first year following repeal, even if the law’s market reforms are kept in
place. CBO and JCT predict that 27 million people would lose coverage if Medicaid expansion
is reversed, and 32 million fewer people would have health insurance by 2026.15

The Urban Institute has reached similar conclusions: if the ACA is even partially
repealed, the number of uninsured Americans would increase by approximately 30 million in
2019, a 103 percent increase.16 If congressional Republicans move forward with repeal, more
people would be uninsured in 2019 than were uninsured in 2009, before the ACA was passed.

13 Council of Economic Advisors, Executive Office of the President, The Economic
Record of the Obama Administration: Reforming the Health Care System (Dec. 2016) (online at
obamawhitehouse.archives.gov/blog/2016/12/13/economic-record-obama-administration-
reforming-health-care-system).
14 Kaiser Family Foundation, How ACA Marketplace Premiums Measure up to
Expectations (Aug. 1, 2016) (online at kff.org/health-reform/perspective/how-aca-Marketplace-
premiums-measure-up-to-expectations); Brookings Institution Center for Health Policy, ACA
Premiums Are Lower Than You Think (July 21, 2016) (online at
www.brookings.edu/research/affordable-care-act-premiums-are-lower-than-you-think/).
15 Congressional Budget Office, How Repealing Portions of the Affordable Care Act
Would Affect Health Insurance Coverage and Premiums (Jan. 17, 2017) (online at
www.cbo.gov/sites/default/files/115th-congress-2017-2018/reports/52371-
coverageandpremiums.pdf).
16 Urban Institute, Implications of Partial Repeal of the ACA through Reconciliation
(Dec. 2016) (online at www.urban.org/sites/default/files/publication/86236/2001013-the-
implications-of-partial-repeal-of-the-aca-through-reconciliation_1.pdf).
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According to the study, approximately 82 percent of those becoming uninsured because of ACA
repeal would be from working families, 56 percent would be Caucasian, and 80 percent would
not have college degrees.17

Reversing the ACA’s Medicaid expansion would be exceptionally harmful to the
residents of states that expanded Medicaid. In these states, such as California, Illinois, and New
York, the uninsured rate would more than double.18 An additional 4 million Americans who live
in states that have not yet expanded Medicaid will lose the opportunity to gain coverage if the
ACA is repealed or the Medicaid expansion is reversed.19 To date, the Medicaid expansion has
been entirely federally funded, generating significant savings for state and local governments. If
the Medicaid expansion is reversed, states are at risk of losing $78.8 billion in federal Medicaid
dollars.20

In addition repealing the ACA and reversing the Medicaid expansion, Republicans in
Congress have proposed taxing workers on their employer-sponsored health insurance. This
change would shift costs onto employees in the form of higher taxes. According to CBO, the
employer tax exclusion subsidizes approximately 30 percent of the average premiums for
employees.21 In 2016, the tax exclusion was valued at about $250 billion.22 This new tax on
employer-sponsored insurance would amount to the largest middle-class tax hike in the last 50
years.

Finally, Republicans have proposed changing current law to allow insurers to charge up
to five times what they charge younger adults. This increase in “rate-banding” would increase
the federal deficit by $11 billion while raising prices by as much as $3,000 per year for older
Americans.23

17 Id.
18 Id.
19 Center on Budget and Policy Priorities, Repealing Health Reform’s Medicaid
Expansion Would Cause Millions to Lose Coverage, Harm State Budgets (Dec. 22, 2016) (online
at www.cbpp.org/research/health/repealing-health-reforms-medicaid-expansion-would-cause-
millions-to-lo se-coverage).
20 House Committees on Oversight and Government Reform and Energy and Commerce,
Democratic Staff, Oversight and Energy & Commerce Dems Release State Fact Sheets on
Impact of GOP Assault on ACA (Jan. 5, 2017).
21 Congressional Budget Office, Private Health Insurance Premiums and Federal Policy
(Feb. 2016) (online at www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51130-
Health_Insurance_Premiums.pdf).
22 Id.
23 The Commonwealth Fund, Insuring Young Adults through the ACA’s Marketplaces:
Options to Expand Enrollment (Dec. 16, 2016) (online at
www.commonwealthfund.org/publications/blog/2016/dec/insuring-younger-adults).
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III. IMPACT OF REPEAL AT THE CONGRESSIONAL DISTRICT LEVEL

The staff analysis examined uninsured rates, private insurance coverage—including
employer-sponsored insurance—Marketplace enrollment and related financial assistance, and
Medicaid coverage, in each of the 435 congressional districts and the District of Columbia. The
analysis found that repealing the ACA would endanger coverage for millions of Americans in
Democratic and Republican congressional districts alike.

A. Constituents in Every Congressional District Saw Substantial Reductions in
the Uninsured Rate That Would be Threatened by Repeal

Based on 2012 and 2015 data from the Census Bureau’s American Community Survey
(ACS), every single congressional district in the country has experienced reductions in the
uninsured rate under the ACA. The average reduction in the uninsured rate from 2012 to 2015
across all congressional districts was 5.4 percentage points. The uninsured rate likely declined
even further in many, if not all, congressional districts in 2016.

Congressional districts in states such as Massachusetts, which had near-universal
coverage prior to the enactment of the ACA, saw the smallest declines in the uninsured rate,
while congressional districts in states such as California and Nevada, which had high uninsured
rates prior to the ACA and took advantage of the ACA’s Medicaid expansion, saw the greatest
reductions in the uninsured rate. Unsurprisingly, congressional districts in states that expanded
Medicaid saw greater declines in the uninsured rate than states that did not—5.8 percentage
points versus 4.9 percentage points on average.

Coverage gains have been achieved through a combination of both Medicaid expansion
and Marketplace enrollment. This analysis examined Marketplace enrollment as of March 2016
in all 435 congressional districts and the District of Columbia, using data from the Kaiser Family
Foundation.24 All congressional districts experienced significant Marketplace enrollment,
ranging from a low of 5,200 enrollees in the 1st Congressional district of Hawaii, represented by
Rep. Colleen Hanabusa (D), to a high of 96,300 enrollees in the 27th Congressional District of
Florida, represented by Rep. Ileana Ros-Lehtinen (R). Across all congressional districts, the
average number of Marketplace enrollees was 26,400.

A large majority of these enrollees are receiving financial assistance to purchase
insurance. The average number of Marketplace enrollees receiving advanced premium tax
credits was 21,500, or approximately 81 percent of all Marketplace enrollees. The average
number of Marketplace enrollees receiving cost-sharing reductions was 14,600, or 55 percent of
all Marketplace enrollees.

This analysis also examined Medicaid expansion enrollment using 2015 Medicaid
enrollment data from the Medicaid Budget and Expenditure System (MBES) analyzed by the

24 Kaiser Family Foundation, Interactive Maps: Estimates of Enrollment in ACA
Marketplaces and Medicaid Expansion (Jan. 10, 2017) (online at kff.org/interactive/interactive-
maps-estimates-of-enrollment-in-aca-Marketplaces-and-medicaid-expansion).
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Kaiser Family Foundation.25 The 19 states that have not adopted the Medicaid expansion
contain 166 congressional districts, while the 32 states and the District of Columbia, which have
expanded Medicaid, contain 270 congressional districts. The average number of Medicaid
expansion enrollees across all congressional districts was 32,800.

These coverage gains are very much at risk as congressional Republicans move to repeal
the ACA through reconciliation. Congressional Republicans intend to eliminate the Medicaid
expansion, make additional harmful cuts to the Medicaid program, and eliminate the premium
assistance tax credits and cost-sharing reductions—replacing them with less generous tax credits
that are unlikely to be sufficient for lower and middle class Americans to afford coverage.26

B. Americans in Private and Employer-Based Insurance Will Also be Impacted
by Efforts to Repeal the ACA

Based on ACS data for 2015, the repeal of the ACA would also deeply impact individuals
in each congressional district with employer-based coverage, who now enjoy important
consumer protections because of the ACA, and individuals with private insurance coverage, who
now have access to preventive health services at no cost.

If the ACA is repealed, more than 150 million Americans with employer-sponsored plans
stand to lose critical consumer protections and benefits that many have gained thanks to the
ACA. These benefits include protection against pre-existing coverage exclusions, prohibition
against annual and lifetime limits on coverage, protection against arbitrary and unfair rescissions
of health insurance policies, and a requirement that insurers allow children to stay on their
parent’s insurance up to age 26.27 On average, 396,200 individuals in each congressional district
stand to lose these consumer protections if the ACA is repealed.

As a result of the ACA, most individuals in private insurance policies now have access to
preventive services such as immunizations, screenings, and annual checkups, without any co-
pays, coinsurance, or deductibles.28 These individuals stand to lose this access if Republicans in

25 Kaiser Family Foundation, What Coverage and Financing is at Risk Under a Repeal of
the ACA Medicaid Expansion? (Dec. 6, 2016) (online at kff.org/medicaid/issue-brief/what-
coverage-and-financing-at-risk-under-repeal-of-aca-medicaid-expansion).
26 Center for Budget and Policy Priorities, House Republicans Would Reverse ACA
Coverage Gains and Radically Overhaul Medicaid, New Talking Points Confirm (Feb. 17, 2017)
(online at www.cbpp.org/research/health/house-republicans-would-reverse-aca-coverage-gains-
and-radically-overhaul-medicaid).
27 Congressional Research Service, Private Health Insurance Market Reforms in the
Patient Protection and Affordable Care Act (Feb.10, 2016) (online at
fas.org/sgp/crs/misc/R42069.pdf).
28 Grandfathered health plans are exempt from this requirement. See Kaiser Family
Foundation, Preventive Services Covered by Private Health Plans under the Affordable Care Act
(Aug. 4, 2015) (online at kff.org/health-reform/fact-sheet/preventive-services-covered-by-
private-health-plans/).
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