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.