Wednesday, June 17, 2015

Victims of an ACA subsidy cutoff may live mainly in Republican districts -- but will they vote?

At Jonathan Cohn's request, Families USA calculated that two thirds of those who stand to lose their health insurance subsidies if the Supreme Court rules for the plaintiffs in King live in Republican Congressional districts (4.2 million subsidized buyers on live in Republican districts, vs. 2.1 million in Democratic districts).

Those numbers appear to support the hypothesis that a Supreme Court decision cutting off subsidies to those who obtained their insurance on insurance on the federal exchange,, may politically damage Republicans, who supported the King plaintiffs' claim that the ACA authorized subsidies to flow only through exchanges "established by a state."  But even if Republican attempts to blame the cutoff on Democrats' poor legislating fail utterly, the demographic profile of those who bought subsidized plans on may moderate the political fallout somewhat.

The vast majority of subsidized buyers on -- 68% -- have incomes under 200% of the federal poverty level (FPL).  Three quarters of customers live in states that have refused the ACA's Medicaid expansion. In those states, the income threshold for eligibility to buy subsidized private plans drops from 138% FPL to 100% FPL, and the percentage of low-income buyers is accordingly higher: fully 50% of buyers in non-expansion states are below 150% FPL, and 73% are below 200% FPL.  While all of the 34 states that abstained from establishing their own exchanges are at least partially Republican-controlled, the 21 that have yet refused to expand Medicaid are more thoroughly Republican-dominated. (On the other hand, many swing states have expanded Medicaid and so have a somewhat wealthier private plan buyer base.)

Lower income citizens are much less likely to vote than wealthier ones. A Pew study of the 2014 electorate, in which turnout was quite low  (as in midterm elections generally), found that while a large plurality of  respondents in the lowest two (of five) rankings of economic security preferred Democrats, only about a quarter of them were likely voters (29% in the second-lowest ranking). Moreover, those lower income voters who favor Democrats are less likely to vote than those who favor Republicans:

The Least Financial Secure Preferred Democrat in 2014, But Many Had No Preference and Most Were Unlikely to Vote
Only 26% of those in the lowest "security" grouping and 32% of those in the second lowest grouping were aware of which party controls the House or Senate. They might be equally unlikely to track which party is responsible for a sudden loss of insurance subsidies.

Pew's economic groupings are based on multiple measures of financial security and don't contain equal percentages of the population; hence they can't be lined up exactly with the income quintiles used by the U.S. Census. But the bulk of customers, with incomes in the 100-200% FPL range, probably corresponds roughly with Pew's second-to-lowest grouping and with the second lowest quintile of the U.S. population.  (A study of income distribution in Washington state from 2005-2009 pegged those with incomes from 100-200% FPL in the second through fourth deciles.) UPDATE 6/19: According to Kaiser, those with incomes from 100-199% FPL make up 19% of the U.S. population, with 15% under 100% FPL. So ACA buyers under 200% FPL are mostly in the second lowest income quintile and partly in the lowest.)

A Demos charting* of  turnout as tracked by the U.S. Census bureau for 2008 -- a year of high turnout, and relatively high turnout among lower income groups --  also shows turnout rising steadily with income -- and only modestly higher in the second and third deciles than in the lowest:

Voter Turnout By Income, 2008 US Presidential Election

A subsidy cutoff might motivate a lot of people in roughly the 20-40% income ranking range to vote. But the cohort that has benefited most from offerings on the federal exchange is generally prone to low voter turnout and low awareness of the positions and actions of the two parties.

UPDATE: Greg Sargent spotlights three swing states with high concentrations of those who stand to their subsidies(also courtesy of Families USA) . The states he spotlights have all refused the Medicaid expansion, and so their private plan beneficiaries are likely to be more concentrated at lower income levels (since those from 100-138% FPL are eligible for subsidized private plans instead of Medicaid). Sargent does acknowledge that many Republican House members may feel that those who stand to lose subsidies are not their natural constituents. He claims merely that a "non-trivial" number of votes may be at stake. That seems fair enough.

* Thanks to R. Subramanian for pointing me to this.


  1. Another good and unique piece, thanks.
    This is why America can simultaneously have a European style welfare state for the elderly, combined with great vulnerability for workers and the poor.
    The elderly are a huge voting bloc, and politicians of both parties respond.

    For example, the total amount spent by the Feds for ACA subsidies in 2015 is supposed to be about $20 billion. This is treated in the conservative press as something close to Armageddon.

    Yet the total amount spent on Medicare is $605 billion, almost all of that going to the elderly. Even in Medicaid, a large portion of the dollars goes to help elderly dual eligibles and nursing home residents.

    But the Tea Party can say "Keep your government hands off my Medicare," and the Republicans can win the 2010 Congress by saying that the ACA would hurt seniors.

    I guess the only answer is far more young voters.

  2. thanks for an excellent article.
    The discrepancy in voting patterns explains why the USA can spend $605 a year in Medicare, plus over $100 billion in the parts of Medicaid that serve seniors, and there is rarely a complaint.

    Yet we spend $20 billion in ACA subsidies, and you think it was the coming of the Great Dspression.

    I noticed this in Tennessee last decade. The TennCare program was helping at leat 15-20% of adult residents. If all the recipients had voted en bloc, they would win every election for 30 years.
    Instead, TennCare funding was slashed and the governor in charge of that was re elected easily.