Medical Patient Drug Care Concept

One of the sad ironies in this nation’s fight over health care is that those with the most desperate need for coverage appear to be supportive of the elected officials most likely to take it away. This strange reality is dramatically reflected in recent analysis conducted by the Kaiser Family Foundation.

Kaiser examined data contained in two large national surveys in order to make state by state estimates of the number of non-elderly individuals with preexisting health conditions. The analysis shows suprising large differences between states. A nonelderly resident of West Virginia for instance is 64 percent more likely to have health conditions that would exclude him or her from coverage as an individual in the same age group in a state like Minnesota or Colorado.

The Kaiser analysis indicates that nationally 27 percent of nonelderly Americans have a preexisting condition that is likely to preclude them from coverage outside the group market. While many Americans with such conditions would continue to retain coverage under group plans even if the House passed bill became law, such individuals would once again be only a “pink slip” away from losing coverage. And many others with such conditions do not have group coverage and would no longer be eligible for Affordable Care Act coverage or coverage that they could likely afford through the new state plans.

In addition, it is important to note that the number of people affected by the treatment of preexisting conditions by private insurers in the absence of the Affordable Care Act is potentially much larger than the number of people with such conditions. Separate polling conducted by Kaiser, indicates that 53 percent of all Americans have an immediate family member with a preexisting condition. As a result the number of Americans who could not get affordable family coverage outside of a traditional group jumps from a little more than a quarter of the nonelderly (27 percent) to more than half (53%).

But these risks are not shared evenly across the country. While the comparison between West Virginia and Colorado is the most dramatic, West Virginia is one of 11 states in which the incidence of such preexisting conditions is above 30 percent or markedly above the national average of 27. On the other end of the spectrum are 13 states in which the incidence of preexisting conditions is less 24 percent or less, significantly below the national average. Non-elderly residents in the 11 high incidence states are more than 36 percent more likely to have preexisting conditions than residents in the 13 low incidence states.

27 states were roughly in the middle with a preexisting condition incidence rate of between 25 percent and 29 percent.

But perhaps the most remark aspect of the Kaiser analysis is when it is compared to the voting returns of the most recent presidential election. Donald Trump, the candidate who opposed the law requiring insurers to provide coverage without regard to preexisting condition, did not do particularly well in the states with low percentages of preexisting conditions and the least to lose with the ACA repeal. He won only 4 of the 13 states in that category.

Trump, however, carried every one of the 11 states in which the percentage of individuals with preexisting conditions was well above the national average. It might be noted that Trump not only won these states but that they are where he scored his largest victory margins carrying them by margins ranging from 18 to 34 percent. The 11 high incidence states provided Trump with 87 of his 306 electoral votes.

A little over half of the states were reasonably close to the national average with respect to individuals with preexisting conditions with rates ranging from 25 percent to 29 percent. Trump won 56 percent of these states or about the same percentage of state victories that he enjoyed nationally (30 of 51 or 59 percent).

The correlation between preexisting conditions is probably stronger than even this data represents. Most states are divided between more affluent urban areas which appear to have lower incidences of preexisting conditions and outlying rural areas where the incidence is lower. These same states also tend to be divided politically along the same lines.

A good example of this would be Virginia in which the affluent Northern Virginia suburbs of Washington, D.C. probably parallel the rates found in low incidence states like New Jersey and Connecticut while the Southwestern portion of the state would be expected to have much higher rates akin to those found in West Virginia, Kentucky and Tennessee—all of which are bordered by Southwestern Virginia.

Trump lost Virginia by a margin of less than 6 percent despite carrying many counties in Southwest Virginia by margins of more 50 or 60 percent because of heavy losses in the healthier Northern Virginia suburbs.

Estimates of preexisting conditions below the state level would, for the same reason, probably reveal that the members of Congress who provided the 217 votes for passage of the recent health care legislation represent a very significant majority of those Americans with such conditions. Analysis of the state level data indicates that states with the highest level of preexisting conditions are currently represented by 67 member of the U.S. House of Representatives and of those 51 or 76 percent voted for the H.R. 1628, otherwise known as the American Health Care Act. The only Republican from any of these states to vote “no” was Thomas Massie of Kentucky who reportedly opposed the legislation not because it failed to cover preexisting conditions but because it did not fully repeal the Affordable Care Act.

Among the 20 Republican members of Congress who voted against the Affordable Care Act, 4 represented states with a low percentage of individuals with preexisting conditions while 15 represented states where the percentage was near average.

The 13 states with the lowest incidence of preexisting conditions were represented by 117 members of the House of whom 31 or 26 percent voted for the measure and 86 or 74 percent voted against it.

The varied incidence of preexisting conditions demonstrated in the Kaiser data and the impact that incidence has on voting behavior and the legislative choices made by elected representatives raise some interesting questions for both national political parties. Why are areas of the country facing the greatest challenges in obtaining affordable health insurance voting for candidates who back legislation that would make that challenge greater?

Is it that other issues are more important to them? Is it that the candidates that they have supported have at least temporarily succeeded in misleading them about the choices we face and the manner in which those representatives would address such choices? Is it a failure of the opposition party to provide a credible alternative narrative or expend the resources necessary to reach voters in these parts of the country?

The coming months should provide us with the information needed to better answer these questions.

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Scott Lilly has been writing about public policy for more than four decades. He is widely viewed as one of the leading experts on the federal budget process and the impact of changes in federal spending policy on local communities, national security and the economy. For 31 years, he worked as a Congressional staffer during which time he directed the staffs of the Joint Economic Committee, the Democratic Study Group and the House Appropriations Committee. He has traveled widely probing the effectiveness of government programs across the U.S. and overseas. He is a Senior Fellow at the Center for American Progress and an Adjunct Professor of Public Policy at the LBJ School of Public Policy, University of Texas. He has testified before numerous Congressional committees and has been a guest on CBS, CNN, Fox News, MSNBC and various other television and radio networks. He has been frequently quoted in the Washington Post, the New York Times, the Los Angeles Times, the Chicago Tribune and other major newspapers.