Don E. Albrecht, Ph.D

Western Rural Development Center Utah State University Logan, Utah 84322-8440 USA

^*Corresponding Author: Don E. Albrecht, Ph.D, Western Rural Development Center Utah State University Logan, Utah 84322-8440 USA.

Abstract
Purpose: Since the Affordable Care Act (ACA) was passed in 2010, millions of Americans without health insurance have declined. More rural Americans than urban Americans have obtained health insurance from the ACA. Despite the program's success, Republicans have made numerous attempts to have the ACA repealed, and Republican voters dominate rural America. This manuscript seeks to understand pastoral support for the ACA repeal.

Methods: Data for the study were obtained from the 2020 Cooperative Election Study (CES), and responses from 49,740 individuals were utilized. Logit analysis was used to explore the extent to which people supported or opposed the repeal of ACA along the Rural/Urban Continuum. Other variables were statistically controlled in the analysis.

Findings: Data analyzed in this manuscript found that persons with characteristics most similar to those who would benefit most from the ACA are most likely to support complete ACA repeal. Significantly, rural residents were more likely to support ACA repeal than urban residents. Most Republicans supported repeal, while nearly all Democrats were opposed.

Conclusions: Individuals tend to support their party platform even if it harms them, their community, or persons like them.

Keywords: Rural, American Care Act, Health Insurance, Politics

Introduction
Residents of the United States spend more money per capita on healthcare than residents of any other country in the world. Despite such extensive expenditures, health outcomes in the U.S. are worse than in other developed nations [1,2]. For example, infant mortality rates are lower and life expectancy higher in much of Europe and other developed countries than in the U.S. [3,4,5,6]. There are also significant health disparities between rural and urban America, with rural America experiencing higher mortality rates than urban America. Further, the gap between rural and urban residents on numerous health measures has grown since the 1980s [7,8,9,10].

A key driver for lower healthcare outcomes in the U.S. compared to other developed countries is that millions of Americans lack adequate health insurance. In every other developed country in the world, universal health care means that everyone has insurance coverage. The adverse health outcomes from a lack of insurance coverage, especially when combined with low socioeconomic status, are significant [11,12,13,14,15,16,17,18]. Persons without insurance do not regularly visit health clinics, are less likely to get surgery when needed, and are less likely to get the prescription drugs that could help them heal. Not surprisingly, persons without health insurance tend to die younger, have higher infant mortality rates, miss work more often, and are more likely to have other health problems than those without health insurance [19,20]. The lack of health insurance is concentrated among the lower socioeconomic strata in the U.S. [21]. Of significance to this study; rural residents have traditionally been more likely to be uninsured than urban residents [22].

To reduce the number of people without health insurance, the Patient Protection and Affordable Care Act (ACA) was passed in 2010 [23]. Since the passage of the ACA, the number of people with insurance coverage has expanded considerably (24). At the time the bill was passed in 2010, 49.9 million Americans did not have health insurance, which was about 16.3 percent of the population; by 2019, the number of Americans without health insurance was down to 26.1 million, or 8.0 percent [25]. Available research indicates that one group that has benefitted extensively from the passage of the ACA is rural residents. Since the ACA, insurance coverage has increased significantly more in rural than urban areas, and the rural/urban gap in the percentage of uninsured has become smaller [26,27,28].

Despite significant and obvious benefits, efforts to repeal the ACA have been ongoing virtually since the bill was passed [23,29,30]. Opposition to the bill appears especially strong among the residents of rural America. In this manuscript, two research issues are explored. First, data are analyzed to determine whether or not rural residents are, in fact, more likely than urban residents to support the repeal of the ACA. Additionally, analysis is conducted to see if rural/urban differences are a consequence of residence or whether differences can be explained by other factors such as socioeconomic status. Second, the literature is explored, and a discussion is provided to help understand why rural people support repealing a program that has significantly benefited their communities. The manuscript continues with an overview of political efforts to achieve universal healthcare in the U.S. A discussion of efforts to repeal the ACA is provided. Factors related to support or opposition to the ACA are discussed, and then data are analyzed to determine rural vs. urban support for the ACA. In the discussion and conclusion sections, an effort is made to understand rural opposition to the ACA.

Efforts to Implement Universal Health Insurance in the U.S.
Throughout the 20th Century, developed countries worldwide began implementing some form of national health insurance policy where every citizen had healthcare coverage. Soon, some form of national health insurance was a reality in every developed country in the world – except the United States. The specifics of how programs are implemented vary from country to country, but in the end, all citizens have health insurance in all of these countries [31,32].

Through the years, there have been several attempts to implement national health insurance in the U.S. During the Great Depression; President Roosevelt attempted to include national health insurance as a part of the bill to create the social security system. The health insurance portion of the bill met opposition and so was removed. Roosevelt did this because he placed high importance on getting the social security portion of the bill passed as quickly as possible. Although he intended to do so, Roosevelt never made another attempt to develop a national health insurance plan. Eventually, World War II required the nation's full attention, and health insurance was removed from the agenda (33). Following Roosevelt's death and the end of World War II, President Truman strongly favored a plan for national health insurance. Those opposing Truman's plan maintained that national health insurance was a socialist conspiracy and represented government overreach. By the time Truman submitted his plan, Republicans had controlled the Senate, and anti-communist feelings were strong due to the emerging Cold War. Consequently, the plan had virtually no chance of passage [34,35,36].

In 1961, President Kennedy began pushing for a national health insurance plan. In response, the American Medical Association (AMA) implemented "Project Coffee Cup," with Ronald Reagan hired as spokesman. Reagan's primary message was that national health insurance was socialism and would weaken our national character [18]. After Kennedy's assassination, President Johnson continued to push federal health insurance as a part of his "Great Society" programs. Because of opposition from the AMA and the insurance and pharmacy industries, Johnson could never pass a program nearly as comprehensive as he had hoped. Eventually, Medicare and Medicaid were passed. These programs provided some form of health insurance for narrow segments of the population (Medicare for older people and Medicaid for low-income people; [37,38,39]).

Despite continual setbacks, many dreamed of a truly comprehensive national healthcare program. When Bill Clinton was elected president in 1992, he placed national health insurance as one of his top priorities. He put his wife, Hillary Clinton, in charge of developing the program. The private health insurance industry responded with a strong advertisement campaign in opposition. These ad campaigns emphasized how a government health plan was un-American and represented the creeping spread of socialism. Entitlement programs would allow people to become complacent and not work as hard. Additionally, they argued the government should remain small and inefficient compared to the private sector. By 1994, it was clear that the Clinton plan had failed [40,41].

The 2008 election of Barack Obama coincided with Democrats gaining control of the House and the Senate. The stage was set for another attempt to create a national health insurance policy. After long and bitter debates, the Patient Protection and Affordable Care Act was passed by Congress on March 3, 2010. Commonly known as the ACA or Obamacare, the bill made health insurance available to millions of uninsured Americans. The plan, however, still needs to be more comprehensive and reach everyone, like plans in other developed countries. Under the coverage provisions of the ACA, those who have coverage from an existing project or Medicare or Medicaid can keep that plan. Those lacking health insurance coverage can get it through an ACA exchange. Low-income persons can get subsidies to help cover costs [42].

An essential aspect of the ACA was Medicaid Expansion, which allows coverage available from Medicaid to be provided to many more people than before. Previously, states had varying levels of who was eligible for Medicaid relative to federal poverty levels. Further, Medicaid was generally available only to adults with dependents, leaving single adults living in poverty completely ineligible. Medicaid Expansion typically makes coverage available to persons with incomes 138 percent of poverty or below. This change made Medicaid available to millions more people. However, a 2012 Supreme Court decision required that whether or not to accept Medicaid Expansion would be left up to the individual states [43]. The cost to the states would be minimal since the federal government covered expenses. The reason a state would not accept Medicaid Expansion would be philosophical rather than financial.

As of 2020, when the data for this study were obtained, 38 states and the District of Columbia had accepted Medicaid Expansion. Not surprisingly, the proportion of people lacking health insurance is much higher in non-expansion states than in expansion states [44]. This is true for people of all income levels – primarily low-income. In 2018, persons lacking health insurance ranged from 2.8 percent in Massachusetts (an expansion state) to 17.7 percent in Texas (a non-expansion state; [45]). Sommers et al. [46] compared some expansion and non-expansion states. They found that state policies had a significant impact on the percentage of people that were uninsured in the different states. Most significantly, ACA has improved health for persons gaining insurance coverage [47]. Specifically, state policies significantly impact life expectancy [48].

Attempts to Repeal ACA
The final vote on the ACA bill was completely partisan – not a single Republican in either the House or the Senate voted for passage. When the ACA was passed, Republicans vowed to repeal it altogether. The arguments were the same as those used since Roosevelt; the ACA represented the spread of socialism, entitlement would make people complacent, and the government was inefficient [49,50]. On several occasions, bills were introduced in Congress to eliminate the ACA; in each case, they failed. At one point, House Republicans refused to fund the federal government unless accompanied by a delay in implementation of the ACA. Democrats refused to bite, and with the subsequent stalemate, the government was shut down for 16 days. Segments of the bill were taken to court in an attempt to have them ruled unconstitutional.

During the 2016 election, Republicans gained control of the presidency, Senate, and House and finally seemed to fulfill their campaign promise to repeal the ACA. In a key, late-night vote, Republican Senator John McCain (Arizona), who was dying of cancer, walked into the senate chamber and signaled thumbs-down. This, along with anti-repeal votes from Republican Senators Susan Collins (Maine) and Lisa Murkowski (Alaska), were the deciding votes in preventing a total repeal from occurring [51]. Even though efforts to completely repeal the ACA failed, attempts continued to weaken the law. For example, in 2017, the Republican tax bill repealed the individual mandate portion of the ACA. Many Republicans vow to try again and eventually get the law repealed.

Understanding Support and Opposition for ACA
In seeking to understand why people would support policies that are economically harmful to them individually or to their community, a growing body of research maintains that in our politically divided world, policy preferences often take a back seat to team loyalty (e.g., [58,59]). As such, some argue that support or opposition to the ACA has little to do with healthcare and is more about supporting the Republican or Democratic Party line [60,61]. The analysis for this manuscript seeks to test this claim by assessing the characteristics of individuals who are most and least likely to support the repeal of the ACA. It is expected that the critical factor will not be whether or not persons like them or persons in their community benefit, but rather the political leanings of the group to which they are a part.

In this analysis, six variables are explored to determine their relationship with support or opposition to the repeal of the ACA. Rural/urban residence is the primary independent variable in this analysis. While rural residents have benefited extensively from the ACA, rural residents are expected to be more likely than urban residents to support the repeal of the ACA. Other independent variables to be explored include whether or not a person lives in a Medicaid Expansion state; a person's political party of preference; a self-assessment of their health; educational attainment, and income. It is hypothesized that support for repeal of the ACA will be more extensive among Republicans, persons not living in a Medicaid Expansion state, persons in worse health, persons with lower educational attainment, and persons with lower incomes. For each of these variables, persons expected to support the ACA repeal are those with characteristics of persons most likely to benefit from the program, or else they are Republican and are keeping the party line.

As scores increase, counties become increasingly isolated from metro centers and have progressively smaller populations. Categories 1-3 are metropolitan, while 4 - 9 are nonmetropolitan. The most urban counties in Category 1 are the 432 counties in metropolitan areas with a population of 1 million or more. A majority of the U.S. population lives in Category 1 counties alone. At the opposite extreme, Category 9 counties are the 408 counties that are entirely rural, with the largest community having a population of less than 2,500 and not adjacent to a metro area. Less than 2 percent of the U.S. population live in categories 8 and 9 combined. For the multivariate analysis, metro counties are compared with nonmetro counties. Metro counties are assigned a code of 1, while nonmetro counties are coded 0.

Five additional independent variables are utilized. First, respondents were placed into two categories relative to whether or not they reside in a Medicaid Expansion state. As of the time of the study, 38 states and the District of Columbia had become Medicaid Expansion states. The 12 non-expansion states were Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. Persons residing in a Medicaid Expansion state were coded 1, while those living in a non-expansion state were coded 0. Second, respondents were asked which political party they preferred. The three possible choices include Independent (coded 1), Republican (coded 2), and Democrat (coded 3). Third, persons were asked about their health. Possible responses were excellent, good, fair, and poor. During the multivariate analysis, answers were placed into three categories that included fair/poor (coded 1), good (coded 2), and excellent/very good (coded 3). Educational attainment was categorized into four groups which included persons with a high school degree or less (coded 1), persons with some college (coded 2), persons with a college degree (coded 3), and persons with a post-college degree (coded 4). Finally, household income was divided into categories that included 1) less than $50,000; 2) $50,000-$99,999; 3) $100,000-$199,999; and 4) $200,000 or more.

For each variable, the category expected to be least likely to support the repeal of the ACA was coded with a higher number. It will thus be the reference category in the multivariate analysis.

The data analysis consists of two parts. First, a bivariate analysis is conducted to provide an overview of the relationship between residence and views toward the repeal of the ACA. The second type of analysis involves logit procedures [63]. This approach was selected because it can be used when there is a dichotomous dependent variable, as in this analysis (support or oppose repeal of the ACA). Logit analysis allows an assessment of the importance of the residential variable when the other independent variables are statistically controlled. A logit analysis with categorical independent variables makes each independent variable's effects evident.

Findings
Table 1 presents data on the percentage who support the repeal of the ACA along the rural/urban continuum. It was found that most respondents oppose the dissolution of the ACA, with only 40.6 percent supportive of repeal. Nonmetro residents (49.0 percent) were much more likely to be supportive of ACA repeal than metro residents (39.1 percent). It is also apparent that support for ACA repeal increases as a person's residence becomes smaller and more isolated. Residents of the largest cities in Category 1 were the least likely to support repeal (36.8 percent). Support increased in the smaller metro areas (Categories 2 and 3). Close to one-half of respondents in all of the nonmetro categories supported repeal. Persons living in Category 5 counties had views similar to the residents of smaller metro counties. Category 5 counties have an urban population of 20,000 or more and are not adjacent to a metro county. These counties are regional economic centers that are similar to urban counties.

Differences were insignificant across the rural/urban continuum on the percentage living in a state without Medicaid Expansion. For political parties, 30.6 percent of respondents stated they were Independents, 27.5 percent were Republicans, and 41.9 percent were Democrats. The data shows that nonmetro residents were significantly less likely than metro residents to be Democrats (30.6 to 43.7 percent). Table 1 data also reveal that nonmetro residents were more likely than metro residents to have fair or poor health, to lack a college education, and to have low incomes.

Table 1: Percent of Respondents Who Support Repeal of the Affordable Care Act, and Circumstances on Other Independent Variables (N = 49,740)

*Differences between Metro and Nonmetro Residents are statistically signigicant at the .01 level

Table 2 provides a bivariate overview of support or opposition to the repeal of the ACA by residents while considering the other independent variables. Persons living non-Medicaid Expansion states were more likely to support repeal than those residing in Medicaid Expansion states. The relationship between the political party and support for ACA repeal was solid. Only 14.7 percent of Democrats supported repeal compared to 77.1 percent of Republicans. Independents were intermediate, and 41.2 percent supported repeal. For the other independent variables, persons with excellent or perfect health were less likely to support repeal (36.3 percent) than persons in good health (38.3 percent), or fair/poor health (44.4 percent), and persons with less education were more likely to support repeal than persons with higher levels of educational attainment. Thus, 49.6 percent of persons with a high school degree or less supported abolition.

In comparison, only 32.9 percent of persons with a college degree and 26.5 percent of those with a post-graduate degree supported repeal. Support for repeal tended to decline as income increased. Also, except for political parties, within each category on the independent variables, nonmetro respondents were more likely to support repeal than metro residents. For example, nonmetro persons with a college degree (43.1 percent) are more likely to support repeal than metro residents with a college degree (32.9 percent), and nonmetro residents with fair or poor health are more likely to support repeal (55.2 percent) than metro residents with fair or poor health (42.9 percent). For political parties, only for Independents were statistically significant differences between metro and nonmetro residents. For Democrats and Republicans, the importance of political parties overwhelmed metro/nonmetro-residential differences.

Table 2: Percent of Respondents Who Support Repeal of the Affordable Care Act by Residence and the Other Independent Variables (N=49,740)

*Statistically significant at the .01 level

The data in Table 3 present summary statistics for the logit model. Table 3 also includes the odds ratio. An odds ratio of one is, in effect, even money. An odds ratio greater than one means that more people with this characteristic support the repeal of the ACA than there are people who oppose repeal. An odds ratio of less than one means that there are more people with this characteristic who oppose repeal compared to those who support repeal. Table 3 shows that all of the independent variables were significantly related to views about repealing the ACA, although the relationship was weak for some variables. Of utmost significance for this manuscript, when the effects of the other independent variables are statistically controlled, the relationship between residence and support for repeal of the ACA becomes very weak. As revealed by the odds ratio, when controlling for the other independent variables, about 104 nonmetro residents support the dissolution of the ACA for every 100 who oppose repeal. There was a relatively strong relationship between residences in a Medicaid Expansion state and support for repeal of the ACA. Even when controlling for the other independent variables, which include political party preference, support for repeal of the ACA was more significant for persons living in non-Medicaid expansion states. This result has clear implications for political efforts in those states to someday approve Medicaid Expansion.

The strength of the chi-square statistic shows that political party was by far the most significant independent variable, with the vast majority of Republicans supporting repeal and almost all Democrats opposing repeal. For Republicans, the odds ratio was 4.3241, which means that for Republicans, the odds of supporting repeal were 4.3 times that of Democrats. Educational attainment was also strongly related to support for ACA repeal. Persons with lower levels of educational attainment are significantly more likely to support repeal than persons with higher levels of educational attainment. For the other independent variables, persons most likely to support repeal are those with worse health and those with lower incomes.

Table 3: Support For Complete Repeal of the American Care Act by Residence and Other Independent Variables (N = 49,740)

Discussion and Conclusions
As the data in this manuscript conclusively show, a solid majority of people oppose repealing the ACA. The political party was very strongly related to support for repeal of the ACA, with the vast majority of Republicans supporting repeal and nearly all Democrats opposing abolition. After statistically controlling for the other independent variables, the metro/nonmetro residence variable becomes very weak, with nonmetro residents only slightly more likely to support repeal than metro residents. The data make it apparent that rural/urban residence does not make a meaningful difference in whether people support or oppose the abolition of the ACA. Thus, the reason a higher proportion of rural people support repeal is not that they are rural but rather that they are more likely to have the characteristics of persons who support repeal of the ACA. That is, they are more likely to be Republican, have fair or poor health, have less education, and have lower incomes.

Beyond political parties, persons most likely to support the repeal of the ACA are those who share characteristics of persons who are most likely to benefit from the ACA. Those most likely to support the dissolution of the ACA were persons living in a non-Medicaid Expansion state, persons with fair or poor health, persons with lower educational attainment, and persons with lower incomes. Statistically, political party and educational attainment were the most vital variables in the model. In general, persons most likely to support repeal share the characteristics of persons lacking health insurance and who could benefit from the ACA.

This raises the vital question of why people would support actions that oppose their best economic interest. Astute observers (e.g., 29,51) have described how the ACA repeal is a prime example of what they call the "Conservative Dilemma." The conservative party (the Republican Party in the U.S.) always gets its primary support from corporations and persons with high incomes. Typically, high on the policy priority wish list for such persons are tax cuts for the wealthy and fewer labor or environmental regulations, which allow them to run their businesses unfettered. The problem is that these programs tend to be unpopular with the general public since the number of people who benefit is negligible and insufficient to win a national election [29]. Thus, conservatives must get people who would not financially gain from programs that benefit the wealthy and may be harmed by such programs to vote for conservative candidates. For this to happen, other issues must be made prominent. In recent years, issues such as abortion, gun control, and immigration have been stressed by conservatives. Further, social programs that may help lower-income persons are targeted as harmful because benefits may go to undeserving minorities who they claim are not committed to a strong work ethic [64,65].

The extent to which Republican efforts to win support from working-class residents with lower incomes and lower educational attainment have been successful is astounding. Republican support for the ACA repeal was overwhelming. Further, as made clear by the analysis in this manuscript, support for the ACA repeal comes most extensively from persons most likely to benefit from the program, such as those with less educational attainment who tend to be in worse health. Indeed, there is nothing wrong with voting Republican and expressing conservative opinions, and such views are necessary in a democracy. However, the concern is when these efforts harm disadvantaged community members. Better education efforts are needed so that people better understand how various policies impact them personally.

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