Obamacare’s Challenge with the Uninsured

Behind all the policy assumptions surrounding healthcare reform and Affordable Care Act, there has been one big political assumption: those without health insurance stand to gain the most. And once the law is in place and the kinks are ironed out those without coverage will likely support the plan.

Looking at the data, the American Communities Project is not so sure – at least not in the short run. Comparing results from the 2012 election to new figures on uninsured in the 15 county types in the ACP, there is little or no correlation. That is, places with high numbers of uninsured were not any more likely to support President Barack Obama in that campaign. And low numbers of uninsured were not directly tied to support for Republican Mitt Romney.

The numbers in the ACP analysis, drawn from 2012 Census American Community Survey data, suggest that attitudes about the health care reform or the ACA have less to do with a community’s uninsured than it does other political and socio-economic factors, including the misunderstood economic concerns of some poorer communities.

It also suggests that even if the bumps in the ACA are ironed out, winning people over in different kind of communities could be more difficult for the Obama administration and for Democrats than many believe.

The numbers above show that the percentage of uninsured really do vary greatly across the ACP – from more than 28% in the 42 counties that make up the Native American Lands to less than 11% in the counties that make up Rural Middle America and the Middle Suburbs.

But those great differences in health insurance didn’t affect how those places voted, or not as much as one might imagine, in 2012 – in a campaign where the ACA was a major issue. The Native American Lands went for Mr. Obama, but just barely, by a little more than 3 percentage points. And Middle Suburbs, voted for Mr. Romney, but only by about 2 percentage points.

Meanwhile the Hispanic Centers, where about 24% don’t have health insurance, actually voted for Mr. Romney, by a slim 3 percentage points.

And these odd, non-correlating differences pop up again and again. The Evangelical Hubs, with large numbers of uninsured, 17%, voted heavily for Mr. Romney, by more than 38 percentage points. The Big Cities, where almost 18% don’t have insurance, went for Mr. Obama by 31 percentage points.

What’s behind those somewhat bizarre splits? There are two points that likely play a role. One concerns the political polarization in the United States. The other concerns more basic bread-and-butter economic issues.

First, the politics. In some ways this discussion over the uninsured takes us back to 2012 campaign and Mr. Romney’s 47% comment. As Dante Chinni noted at that time of that story, many of the 47% were actually Mr. Romney’s voters.

But in many of Mr. Romney’s biggest supporting communities in 2012 – the Evangelical Hubs, Working Class Country and, to a lesser extent, Graying America – political discussions are not about dollars and cents as much as they are about values and beliefs.

People in these communities have a strong distrust of government and to them the ACA represents a government incursion into the private market place. And ideology and political belief can trump whether one is a “winner” or “loser” on a specific policy. Some things are more important to people than their personal economic situation. Many people in these same communities tend to oppose government program like food stamps even though people in them often benefit.

Second, beyond the cultural/political concerns about the ACA, there are the simple costs. These communities with large numbers of uninsured are, for the most part, poorer than the nation at large and that means the cost of everything – from food to gas to insurance – is closely scrutinized.

There are seven county types in the ACP that have more than 15% uninsured, and six of them have median household incomes below the national median of about $50,000 – the Evangelical Hubs, Working Class County, Native American Lands, Hispanic Centers and the African American South are all below $44,000. They don’t have a lot of money to spend and even if they want health insurance, the requirement of having to buy it is a different matter.

Yes, subsidies will make a difference for many in those places, but some of those households are struggling mightily in the modern economy and even having to spend a $100 a month might be seen as a stretch.

In reporting in communities with low insurance rates, the ACP has found that the desire for insurance varies greatly even among those without it. In Lincoln City, Oregon, an aging community, as well as El Mirage, Arizona, a small Hispanic community on the edge of Maricopa County, residents said they were as concerned about the cost of insurance as going without insurance.

(As Dante Chinni wrote in the Wall Street Journal’s Politics Counts blog, states with large Hispanics populations seem to registering very slowly for a variety of reasons.)

This is the other side of the health care reform debate. While much of the discussion about the uninsured has been about young invincibles who are sure they will never get sick or injured there is a large chunk of Americans who might be called pragmatic gamblers.

The pragmatic gamblers are not necessarily young and do not have insurance, but they also feel the system, broken as it may be, works fairly well for them. They go to the emergency room if they need treatment and work out an arrangement to pay what they can.

Of course, there is a chance that something catastrophic could befall them, but for these uninsured that’s a risk they are willing to take. Their money is tight enough that having more in their bank account is worth the risk. More study of this group of people and these communities is needed and over time enrollment rates may tell the tale.

But for now, the point to keep in mind is that the uninsured may not end up as supportive of the ACA as some expect. It may be that once the systems for the new law are up and running and the uninsured have come to understand it, they will become big fans of the law. But these numbers suggest that outcome is no certainty.


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