Toward An Understanding of Rural Support For ACA Repeal

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 Despite the program's success, Republicans have made numerous attempts to have the ACA repealed, and Republican voters dominate rural America.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.


Introduction
Residents of the United States spend more money per capita on healthcare than residents of any other country in the world. Despite 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 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. 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.

Efforts to Implement
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  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. 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 levelsprimarily low-income.
In 2018, persons lacking health insurance ranged from 2.

Understanding Support and Opposition for ACA
Why is there such strong opposition to national health insurance, particularly the ACA? Ongoing research since the act's passage has found opinion deeply divided, generally along political lines [52], with Republicans supporting repeal and Democrats opposing repeal.
Once implemented and people begin receiving the benefits, social programs become widespread, entrenched, and challenging to repeal [51]. Analysis by Iglehart [43] found that if repeal efforts are ever successful, the negative impacts for rural areas would be substantial. Republican elected officials are not concerned that supporting the ACA repeal will hurt them politically. In fact, failing to advocate for the repeal of the ACA may be politically harmful.
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., 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  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. 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.  For political parties, only for Independents were statistically significant differences between metro and nonmetro residents. For

Findings
Democrats and Republicans, the importance of political parties overwhelmed metro/nonmetro-residential differences. 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.  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. 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 workingclass 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.