How many in your county would be most vulnerable to Obamacare repeal?

Editor's note: Some of the following article was originally published in January. It has been updated to reflect the release of an Affordable Care Act repeal bill in the U.S. Senate.

Hundreds of thousands of state residents would likely be affected by a repeal of the Affordable Care Act, with many counties that threw their support behind President Donald Trump in the 2016 presidential election having a higher proportion of affected residents, according to a Bridge Magazine analysis of government data.

The Senate released its version of Obamacare repeal today. And while the bill is expected to be tweaked before a vote – which could be held as soon as next week – the bill, if it becomes law, would undeniably result in major changes to health care in Michigan. The implications of a repeal of the ACA could be felt by nearly 1-in-10 Michigan residents, and as much as 13 percent of the population in places as different from one another as urban Wayne County and rural Emmet County.

Consider: In Wayne County, dominated by heavily Democratic Detroit, 12.7 percent of county residents receive health care through a combination of ACA enrollment or Medicaid expansion. In Cheboygan County, at the top of the lower peninsula, where Trump trounced Democratic nominee Hillary Clinton by a 2-to-1 margin, 13.1 percent of residents depend on ACA coverage or Medicaid expansion. Medicaid expansion, which extends Medicaid coverage to individuals and families whose incomes are above the traditional Medicaid program cutoff, would be phased out in both the Senate and House plans.

Impact of ACA repeal in Michigan

Nearly a million people in Michigan get their health coverage through the ACA or Medicaid expansion, helping cut in half the percent of people who don't have health insurance. Click or tap on a county or congressional district to see how many people are covered by Medicaid expansion and the ACA.

By county

By congressional district*

*Estimates based on county-wide numbers. Some counties are split among two or more congressional districts. Source: State and federal health data on Medicaid and the ACA enrollment.

Since the ACA went into effect in 2013, the percentage of state residents without health insurance fell from 11 percent to 6.1 percent, according to U.S. Census data from 2015. It’s likely even lower today though, as Republicans are quick to note, premiums for ACA-bought policies continue to rise.

A vote for change

In Michigan, some counties with the highest Medicaid expansion and ACA usage gave Trump some of his largest victory margins (he won the state by just over 10,000 votes).

In Oscoda County, between Grayling and Lake Huron in northern Michigan, more than a quarter of residents get Medicaid – traditional or through the expansion – or bought a policy through the ACA. It’s one of the highest rates in the state. So too is the support it gave Trump, who received 70 percent of the county vote; Trump performed better in only two other Michigan counties.

Conversely, urban areas like Wayne County, where more than 30 percent of residents get Medicaid (traditional or through expansion) or bought an ACA policy, went for Democratic nominee Hillary Clinton in big numbers. She promised to preserve the ACA.

More than 630,000 people were added to the state’s Medicaid rolls since early 2014, when the Michigan Legislature voted to expand coverage for the poor. The ACA offered additional federal funding to states to cover those making up $33,000 for a family of four or $16,000 for a single person. (The limit for traditional Medicaid is just below $25,000 for a family of four and $12,000 for an individual.)

The plan, approved by the Michigan Legislature with the vast majority of Democratic legislators and a minority of Republicans, went into effect in early 2014 and has seen hundreds of thousands sign up across the state. In many northern Michigan counties, the expansion doubled the number of people eligible for Medicaid.

Then, beginning in 2014, residents were able to buy private health insurance through the federal exchanges. As of late last year, more than 345,000 Michigan residents were covered by ACA-bought policies.

Charles Gaba, a Bloomfield Hills web developer, began collecting and disseminating data on the ACA in 2013 and has become a reliable source for ACA data to both the media and politicians. He estimates that two-thirds of those who bought a private policy through the ACA and all of those who are on the Healthy Michigan plan could be directly affected by repeal.

And that doesn’t count roughly one million state residents who benefit from traditional Medicaid coverage, which could also see substantial changes under the bill passed by the House and the bill now being considered in the Senate. The Senate bill would offer states the option of receiving Medicaid dollars as a block grant program similar to welfare, which would send money to the states while giving them greater flexibility on how to spend it.

Those plans make some advocates for the poor nervous, in part because of how states, including Michigan, have historically handled other block grant programs. Bridge wrote last year about how some block grant money for the poor ended up funding scholarships at private colleges in the state for more affluent students.

“The Affordable Care Act is not perfect but it has provided a significant benefit to working families across Michigan,” Rep. Debbie Dingell, D-Dearborn, said in response to Bridge’s inquiry in January. “We cannot afford to go backwards, and I will be fighting tooth and nail to protect the health care coverage” of those receiving coverage through the ACA.

To ACA supporters, the number of beneficiaries – nearly a million across the state – should give Congress pause before it makes major changes to a program that benefits so many in Michigan and across the country.

“One would hope that the congressional delegation is responsive to its constituents,” said Marianne Udow-Phillips, director of the Center for Healthcare Research & Transformation, a nonpartisan health care research center based at the University of Michigan.

“The president’s health-care law has led to double-digit premium increases, rising deductibles, and dwindling choices for consumers,” said one, Rep. Tim Walberg, R-Tipton, in a January statement. “Obamacare is collapsing and families who are hurting need relief. To fix this broken system, we need to repeal Obamacare and have a stable transition to patient-centered health care solutions that give families more choices and lower costs.”

Both U.S. Senators, Democrats Gary Peters and Debbie Stabenow, defended the ACA to Bridge in January, and, like others in their party, said they do not favor repeal but largely agree that the ACA can be improved, though they too weren’t terribly specific on how.

“The Affordable Care Act must be preserved. The evidence of its benefits are clear in our state,” Rep. Sandy Levin, D-Royal Oak, said in statement. “The protections in the law are also vital so that no one can be denied coverage because of a pre-existing condition or women are not charged more for their care.”

Benefits from…somewhere

Udow-Phillips, a former director of the Michigan Department of Human Services, acknowledged that the ACA has problems, including premium increases averaging nearly 17 percent, and needs to be amended. But she said it might get more support if more of its beneficiaries were aware of who they are. She said some who benefit from Medicaid expansion don’t know that they are benefitting from “Obamacare” in part because Michigan calls its expansion program Healthy Michigan” with no mention of Medicaid or the ACA.

“A lot of people didn’t realize they got coverage because of the Affordable Care Act,” she said. “Communication around this law has been terrible by advocates for the law.”

For critics of the ACA, Trump’s election has created an opportunity to focus on those who’ve been harmed because their premiums rose sharply, their insurance shifted to higher deductibles, or they lost job opportunities because of high insurance costs.

“It’s very easy when you talk about the possibility of repeal that you’ll be able to identify and swing a camera and find some people who would lose their coverage. It’s true and unfortunate. (But) right now the existence of the law has some very serious negative effects on a lot of people,” said Robert Graboyes, a senior research fellow focusing on health care at the Mercatus Center, a market-oriented research center at George Mason University in Virginia.

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Thu, 06/22/2017 - 3:18pm

Here's a question for you. How many can afford the co-pays and deductibles of the ACA in its present form? How many can afford the average 31% increase in premiums this year? How soon before the ACA has only 1 company offering insurance in any given district?

Chuck Fellows
Thu, 06/22/2017 - 7:22pm

Please explain why Medicare works with a 4% overhead versus the 15% and up for private insurers. Please explain why hospitals refuse to make their "chargemasters" public, why a republican Congress refused to allow Medicare to negotiate drug prices, and please explain why republicans abandoned their idea for a mandate the instant Obama became president.
Finally, please explain why universal health care in other developed countries provides high quality care, greater longevity at lower cost.

Fri, 06/23/2017 - 10:17am

If the criteria isn't the same then the comparison of results is not valid. Also each of us make presumptions [which always bias how we see the data] about what we are expecting from whom and what we want the data to prove.

Have you considered those collecting and reporting the data may have different criteria for how they define/categorize the data?
Do you really believe that the people in different settings don't use different criteria because of the nature of the audience they are reporting to? Look at any data whether it be medical statistical analysis where in one report claims 'coffee' is bad for people and the next that claims it is good, similarly accounting data can be reported differently. We need to know the nature of the audience and the purpose of the reporting at a minimum to decide whether the comparison has any value. If you are a government department trying to get more money from the legislator are you going to report how effective your efforts are or how desperately you need more money.
Unless there is a set of standard criteria that is used by all then you must consider it the classic comparing 'apples' and 'oranges.' It is all money but who, why, and how they report it all had to do with the audience it is being reported to.

If you doubt this consider the original reports on the ACA [Obamacare] and how the CBO reported how much it would save over ten years and yet here we are and not even the creators and supporters would claim any of those numbers happened. The CBO only reports on what and how the question [data expectations] are presented. If the premise is everyone will enroll then there data shows one result, if reality is the not that many did enroll then their reporting data had no value.

Question; which one of these reporting organization have the risk of legal action if they manipulate the numbers they report? Which has the most latitude in how they report the numbers?
As much as I would like to trust to the numbers being reported, I am always wondering how the numbers are developed and who is looking over their shoulders to verify the accuracy of the numbers. Who watches over the shoulder of the government, the government watches over the shoulder of private industry.

As for how the rest of the world reports their medical care success, again is it significantly dependent on how they define the numbers. As an example, a few years ago I wonder about how disappointing the USA infant mortality compared to other nations, it turned out that in the US it didn't matter the potential of survival if a baby was born 'alive' it was considered a baby for data sake, while in other countries [including western European] that they didn't consider a baby in the data unless it had survived 1 year. Do you think the comaprison of the US to the rest of the world is valid if for infant mortality? Why? When do you think the highest risk is for a baby, especially those where the mothers prenatal care is all but non-existent and she is an active drug user?

If the criteria isn't the same then the comparison of results is not valid.

Even when comparing the US to Canada does the availability of diagnosis and treatment a factor in the data. This is based on anecdotal, if the only MRIs available are in Toronto what is the access to people in the rest of Ontario? If a person dies before diagnosis [because of limited access] does the case enter the medical system accessment data or since there was no verified diagnosis are the left our of the system? In the US if a doctor has a concern a person can have an MRI in one or two days. A distant family member, had over a 6 month delay in an MRI even though his symptoms warrant such testing. Several years ago a fiend moved his mother to live in the US as she was too old [in her 60s] to qualify for dialysis in Canada, she received it in his small town here. Be sure of the criteria use before placing too much weight a comparison.

Kevin Grand
Thu, 06/22/2017 - 3:33pm

And "buried" at the end:

"A record number of people have high deductible health plans with average deductibles for individuals with employer coverage in Michigan increasing from $571 in 2006 to $1,431 in 2015, making it difficult for some to afford the cost of care.

The 2017 average Michigan individual market rate increase of 16.7% and the reduction in the number of health plans offering coverage in some areas of the state left some with large premium increases and fewer choices of plans.

Some people cannot find coverage that includes the doctors and hospitals that they want given that more than 80% of plans offered on Michigan's Health Insurance Marketplace in 2017 are plans which have narrow provider networks."

Is it honestly necessary to remind everyone of the "If you like you plan you can keep it. If you like your doctor you can keep them. Americans will see on average $2,500/year in savings"-lie that Pres. B.O. promulgated to the "stupid people"?

Obamacare CANNOT be fixed, because it was never meant to work in the first place. Pres B.O. even said so himself;

"I happen to be a proponent of a single-payer universal health care program. I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its gross national product on health care, cannot provide basic health insurance to everybody."

One need to look no farther than California to see just how that "solution" will work.

And that is only one state.

Mike Stpierre
Thu, 06/22/2017 - 11:54pm

Just like in Kentucky. Obamacare expansion was called Kynect. Kentuckians loved it! Hated Obamacare! Ha ha!
I bet the same was true here in Michigan. With the "Healthy Michigan " moniker!
Hope those trumpy voyears up north don't get stung too bad!

Fri, 06/23/2017 - 2:13pm

The real lesson from Obamacare is the same lesson that should have been learned from the State revenue sharing; anytime you give up the hard part [taxing] to pay for the promises of 'free' services ensures those who made the promises will take away the money and the locals are left cleaning up the mess.

Obamacare promises were 'if you like your doctor you can keep him', 'if you like your plan you can keep it', and we will get money from the rest of country so you won't have to pay for it. Does that sound a lot like 'revenue sharing'?

Health care cost will continue to rise as people make bad lifestyle choices, and medical research continues to be successful, and the political promises of someone else will pay for it continues.

You seem to disdain the rural [northern] Trump voters, I wonder is you ever consider how much is spent on the health of those voters versus the urban Hillary voters and non voters.

My hope is those Hillary voters [along with all voters and no voters] making healthier lifestyle choices so the Trump voters [all voters] have less care to pay for.

A simple first step is to have services such a lab [blood] testing post their prices so patients can choose.

Fri, 06/23/2017 - 3:16pm

I think it's safe to say that Americans are a generally compassionate people who hate to see suffering and but generally avoid deep linear thinking . This is a different question than what is the best method to deliver health care to our indigent population. The ACA keeps the conflicted incentives that have driven our healthcare expenditures to the levels of absurdity while placing the primary burden on the producers and asking little of the recipients. (For being so great both Medicare' and Medicaid's s outpacing their original cost projections are best measured on a Rector scale that the typically linear graph.) Long term it seems that the ACA is designed to intentionally and unavoidably morph our Healthcare financing program out of private insurance and into a Medicaid for All program, with cost and quality driven consequences that are best represented by Brave New World and inner city public schools. To the embarrassment of the left, those with the resources will still by-pass this public system for privately financed care, (think Obama sending his daughters to Sidwell Friends rather than Washington Public schools)! Good luck!

Sun, 06/25/2017 - 9:43pm

Back to if you don't have decent and affordable insurance just go to the E.R. and have the ones who are rich enough to be insured pay for it. LOL and then there's always just don't pay or pay like $5.00 per month to prove that you are "making an attempt" (they can't take your home or your vehicle--well, not until trump and the republicans greedily change that) And there's also the medical tourism thing where they can go to 3rd world countries to receive complete and better care than this country is willing to give poor people. Good job America! Christian and moral equality, and fairness for all of mankind working at it's best! Impressive , eh?