Researchers find links between states' voting patterns and health insurance coverage

Researchers at Case Western Reserve University reviewed national data from the U.S. Census bureau and found associations between states' voting patterns in the 2016 presidential elections and decreases in the number of adults 18 to 64 years of age without health insurance coverage.

Following the implementation of the Affordable Care Act (ACA), we observed sharp decreases in the number of uninsured Americans nationwide. However, since the 2016 presidential election, these gains are reversing in so-called 'red' states, and 'purple' states that flipped from blue to red."

Uriel Kim, lead author on the study and an MD candidate at the Case Western Reserve University School of Medicine

The paper State Voting Patterns in the 2016 Presidential Election and Uninsured Rates in Non-elderly Adults was recently published in the Journal of General Internal Medicine.

Kim and colleagues at the medical school defined states based on voting patterns in the 2016 general election, categorizing them as Blue (21 states and Washington, D.C.), Red (24), or Purple (6)--states that switched from Blue to Red in the 2016 election. (No Red states switched to Blue.)

"The implementation of Medicaid expansion and the marketplaces has varied across states, at least partially explaining our study findings," Kim said. "For example, of the 14 states that have not expanded Medicaid, most are red or purple states. Additionally, while all Americans have access to the insurance marketplaces, the degree to which states invest in outreach and navigation programs for marketplace insurance generally varies along party lines."

In the years 2014 through 2016 (compared to 2013, before key provisions of the ACA were implemented), the data showed that the number of uninsured adults age 18 to 64 decreased by 15.8 million nationwide.

• Blue states saw a decrease in the uninsured of over 7.6 million.
• Purple states saw a decrease in the uninsured of nearly 3 million.
• Red states saw a decrease in the uninsured of nearly 5.2 million.
• While the number of uninsured Americans reached record lows in 2016, over 23.5 million remained uninsured.

From 2017-18, following the presidential election, the number of uninsured individuals increased by more than 850,000 nationwide, reversing the positive trends.

• Blue states saw a negligible decrease in the number of uninsured.
• Purple states saw the number of uninsured grow by 240,000.
• Red states saw the uninsured grow by 620,000
• Over 24.3 million were still uninsured by 2018, with the majority living in Red states.

Tables and the full study are available in the paper here. Data from 2019 and 2020 were not yet available for the researchers to review.

The ACA expanded coverage with two approaches: the expansion of Medicaid (in some states) to individuals with higher incomes and the creation of "marketplaces" (in all states) that allow individuals to purchase health insurance for themselves and their families. Individuals purchasing insurance on the marketplace receive sliding-scale subsidies based on their income.

The study's senior author, Siran Koroukian, an associate professor in the Department of Population and Quantitative Health Sciences in the medical school, added that the study highlights the importance of policies to enable health care access, which has particular relevance during the COVID-19 pandemic and the resulting economic fallout.

"Since the majority of Americans receive insurance through their employer," said Koroukian, "the rise in unemployment following COVID-19 could mean that millions of people could be left without any insurance coverage, especially in states with less robust Medicaid programs or insurance marketplaces. This is problematic when the ability to access care is essential."