How many people have ACA healthcare coverage in YOUR Congressional District?

Wed, 11/20/2024 - 6:57pm

IMPORTANT: See caveats below regarding the impact of Medicaid Unwinding & other enrollment changes over time on these estimates.

(sigh) Annnnd here we go again. With another GOP trifecta and Trump's Project 2025 promising draconian cuts to federal spending, there's a very good chance that the Affordable Care Act is, once again, on the chopping block.

I have no idea what's going to happen to either it, Medicaid, Medicare, the Children's Health Insurance Program (CHIP), the VA or the Indian Health Service, but whatever it is probably isn't gonna be pretty.

With that in mind, I figured it would be helpful to take stock of just how many Americans are actually receiving healthcare coverage through the ACA...and while I've crunched this number several times before (spoiler: the grand total is a little shy of 45 million people nationally), I'm taking it several steps further this time and breaking it out not only by state, but by Congressional District (CD).

To be clear, I'm hardly the only one going down this route. Back in May, the Center for American Progress (CAP) published their own variant on this. However, theirs only focused on the the portion of the under 65 population in each CD with exchange plans (including a breakout between subsidized and unsubsidized enrollees), and their analysis only included the 32 states hosted by the Federally Facilitated Marketplace (FFM; HealthCare.Gov), while not including the 18 states (+DC) which operate off of their own marketplace platforms.

CAP explains their methodology as follows:

Notes: The Centers for Medicare and Medicaid Services reported data on all marketplace plan selections and plan selections with APTCs, rounded to the nearest thousandth enrollee. “AL” refers to “at large.” A small number of people ages 65 and older—who do not qualify for premium-free Medicare Part A coverage—are eligible for marketplace enrollment with financial assistance from APTCs. Nationally, an average of 1.7 percent of 2024 open-enrollment marketplace plan selections were made by people ages 65 and older; for the purpose of this analysis, total plan selections apply to all ages, while nonelderly population statistics are limited to those under the age of 65. United States totals include plan selections on both the federally facilitated marketplace and state-based marketplaces (SBMs); totals in this table will not reflect U.S. totals. Washington, D.C., and Vermont operate their own state-based marketplaces, but because they only have one congressional district, the state-level estimates were included in this table.

Source: Centers for Medicare and Medicaid Services, “OE 2024 Healthcare.gov Consumer Estimates by Congressional District,” (last accessed April 2024); Centers for Medicare and Medicaid Services, “2024 OEP State-Level Public Use File,” (last accessed April 2024); U.S. House of Representatives, “Directory of Representatives,” (last accessed April 2024); U.S. Census Bureau, “ACS Demographic and Housing Estimates: 2022,” (last accessed April 2024)

More recently, in July, KFF published an analysis of how much net ACA premiums would increase if the upgraded financial subsidies provided by the Inflation Reduction Act are allowed to expire next year...including breaking it out by Congressional District. In their case they presented it as a cool interactive map, although it was sort of buried 2/3 of the way down the analysis. This is more useful for my purposes since it includes all 50 states & DC.

KFF explains their methodology as follows:

Note: This congressional district map does not account for corrections submitted by Arkansas and published by the Census Bureau on December 16, 2022. The vast majority of states will use the same Congressional District lines in the 2024 election for the 119th Congress as in 2022 for the 118th Congress. Some states have finalized changes to their Congressional District lines for the 2024 election while others are currently in litigation.

Source: KFF analysis of Missourri Census Data Center GeoCorr 2022 tool, 2024 CMS State and County-Level Public Use Files, and SBM Open Enrollment Reports

However, like CAP, they were again focusing purely on exchange QHPs (Qualified Health Plans), so they didn't include Medicaid expansion or Basic Health Plan (BHP) enrollees, who combined actually make up more than half of total ACA-specific healthcare coverage.

Fortunately, I was also able to find a third analysis which helps fill in the puzzle: In September, the Association for Community Affiliated Plans (ACAP) published estimates of Medicaid & CHIP enrollment broken out by Congressional Districts...including a separate column for ACA Medicaid expansion enrollees.

ACAP explains their methodology as follow:

ACAP analysis of CMS Statistical Enrollment Data System (SEDS) data cross-referenced against U.S. Census data from the 2022 American Community Survey.

Between these three publications and their sources, I have the core data I need to compile a detailed breakout of ACA exchange QHPs and Medicaid expansion enrollment.

I haven't found similar data for the Basic Health Plan programs in New York or Minnesota (or for Oregon, which just launched their BHP program in July), but since BHP enrollment is limited to those who earn between 138 - 200% of the Federal Poverty Level (FPL), just a bit higher than the cut-off for Medicaid expansion enrollment, they should follow very similar population demographics. In other words, I'm assuming that if 10% of Medicaid expansion enrollees within the state are in a given CD, roughly 10% of BHP enrollees for that state should be in that CD as well. This isn't ideal, of course, but it's the best workaround I've come up with.

This left me with one other problem: The timing of the data:

Having said that, I'm operating on the assumption that within each state, the proportional changes in enrollment since 2022 within each Congressional District have been fairly proportional. That is, if statewide enrollment dropped by 20%, I'm assuming that each CD similarly saw roughly a 20% drop.

I recognize that this is a major assumption, but again, for the moment it's the best I have to work with.

Beyond that, for my own deep dive, I'm trying to ensure the data is as up to date as possible since in addition to Medicaid Unwinding there have been other, smaller enrollment changes in all of these programs changes over time, some of which only impacted one specific state.

For example, in addition to the Medicaid Unwinding factor...

  • North Carolina expanded Medicaid under the ACA in December 2023. Enrollment has gradually ramped up, reaching 346,000 in February, 500,000 as of July and stands at 577,107 as of this writing. This also means that NC QHP enrollment has dropped significantly (those in the 100 - 138% FPL income bracket), but that should have already been reflected in the February Effectuation data.
  • New York expanded their Basic Health Plan (BHP) program, called the Essential Plan, up to 250% FPL starting in April 2024. While this has dramatically increased NY BHP enrollment, it also reduced NY QHP enrollment somewhat since any exchange enrollee in the 200 - 250% FPL income bracket has been transferred over to the Essential Plan instead.
  • Georgia continues to prove how ineffective imposing work requirements onto Medicaid eligibility is; their "GA Pathways" program only had 4,200 enrollees as of June 2024. Of course, "ineffective" assumes discouraging enrollment isn't the entire point of the program in the first place...
  • Other various states have also published updated enrollment data for exchange QHPs, Medicaid expansion or both.

In each of these cases, I'm assuming that any statewide increase or decrease from the baseline data I have (February 2024 for QHPs; 2022 for Medicaid expansion) is proportional across each CD. Again, not ideal but the best I can do with the data available to me.

Some additional notes:

  • I've updated the Representatives to reflect the results of the 2024 election, since it's the upcoming Congress which will face any political fallout from policy changes to the ACA or Medicaid. This includes changing the color coding in cases where the districts flipped to or from R/D control.
  • As of this writing there are still 3 House districts with unknown outcomes (CA-13, CA-45, IA-01), plus one Vacancy (FL-01).
  • The two columns with yellow headers are the "baseline" CD breakouts for exchange QHPs (effectuated enrollments as of February 2024) and Medicaid expansion (MBES enrollment as of March 2024).
  • The columns to the right of these in green reflect states where I've been able to find more recent enrollment data for either QHP or Medicaid expansion, ranging anywhere from June to November 2024. The districts with more recent data are in green. I've included direct links to the various state DHHS enrollment reports/dashboards below the main spreadsheet. In some states I haven't found more recent data; in others the reports/dashboards are too confusing for me to be confident that I'm interpreting them correctly. In both of these cases I'm sticking with the baseline numbers for now.
  • The BHP enrollment data is from either October or November for all 3 states (MN, NY, OR) and comes directly from these states DHHS departments. Again, I'm assuming that CD-level enrollment in BHP coverage is proportional to Medicaid expansion enrollment in all 3 states.

As you might imagine, this has proven to be a massive undertaking requiring an equally massive spreadsheet, which I've uploaded to Google Sheets for folks to review. I've also embedded it here below, though this obviously requires a lot of scrolling around. I'll add some key takeaways below:

Key Takeaways:

  • The District with the highest percent of its total population enrolled in ACA exchange plans: Florida's 27th House District, represented by Republican Maria Elvira Salazar, where a stunning 34.3% of the entire population is enrolled in ACA exchange coverage according to KFF.
  • This is particularly stunning given that Florida hasn't expanded Medicaid...that entire 34.3% is exchange enrollment only.
  • There's a total of 9 Districts where more than 20% of the total population has ACA exchange coverage...all of which are in Florida:
    • FL-27: Maria Elvira Salazar (R) 34.3%
      FL-24: Frederica S. Wilson (D) 33.5%
      FL-28: Carlos A. Giménez (R) 32.9%
      FL-09: Darren Soto (D) 30.5%
      FL-26: Mario Díaz-Balart (R) 29.7%
      FL-10: Maxwell Alejandro Frost (D) 26.5%
      FL-25: Debbie Wasserman Schultz (D) 26.3%
      FL-23: Jared Moskowitz (D) 24.2%
      FL-20: Sheila Cherfilus-McCormick (D) 24.0%

Conversely, not including the U.S. territories (which ACA exchanges don't operate in), there are 8 House Districts where less than 1% of the total population is enrolled in ACA exchange plans...all of which are located in New York. However, there's an important reason for this: New York is one of just 3 states operating a Basic Health Plan program, which essentially cannibalizes exchange enrollees earning up to 200% FPL. When you include BHP enrollment, all 8 of these districts jump to between 7 - 15% of their populations being enrolled in either QHPs or BHPs.

  • The CD with the lowest ACA exchange enrollment as a percent of total income outside of New York is Hawaii's HI-01 (Ed Case, D) at 1.1%.
  • There's a total of 10 CDs (again, not including NY) where less than 2% of the population is enrolled in exchange plans:
    • MN-01: Brad Finstad (R)
    • KY-06: Andy Barr (R)
    • DC-AL: Eleanor Holmes Norton (D)
    • KY-01: James Comer (R)
    • KY-03: Morgan McGarvey (D)
    • HI-02: Jill Tokuda (D)
    • KY-02: Brett Guthrie (R)
    • KY-04: Thomas Massie (R)
    • KY-05: Harold Rogers (R)
    • HI-01: Ed Case (D)

Again, a couple of caveats are important here: Minnesota, like New York, has a robust BHP program, and Medicaid eligibility extends up to 210% of the Federal Poverty Line (FPL) in the District of Columbia.

So what happens when you include Medicaid Expansion and BHP enrollment into the mix?

  • There's 16 CDs where more than 25% of the total population is enrolled in some form of ACA-provided healthcare coverage: 
    • NY-15 Ritchie Torres (D): 36.4%
    • FL-27 Maria Elvira Salazar (R): 34.3%
    • FL-24 Frederica S. Wilson (D): 33.5%
    • FL-28 Carlos A. Giménez (R): 32.9%
    • NY-13 Adriano Espaillat (D): 32.3%
    • FL-09 Darren Soto (D): 30.5%
    • NY-08 Hakeem Jeffries (D): 29.9%
    • FL-26 Mario Díaz-Balart (R): 29.7%
    • NY-14 Alexandria Ocasio-Cortez (D): 27.6%
    • NY-09 Yvette Clarke (D): 27.3%
    • FL-10 Maxwell Alejandro Frost (D): 26.5%
    • FL-25 Debbie Wasserman Schultz (D): 26.3%
    • CA-21 Jim Costa (D): 26.1%
    • CA-22 David Valadao (R): 25.4%
    • NY-06 Grace Meng (D): 25.3%
    • CA-13 ??? (?): 25.3%

Note that CD-13 is still uncalled; it's currently held by a Republican but may have flipped to a Democrat.

  • At the opposite end, here's the 12 CDs with the lowest percent of the total population enrolled in any form of ACA coverage:
    • KS-04: Ron Estes (R) 6.2%
    • KS-03: Sharice Davids (D) 5.8%
    • KS-02: Derek Schmidt (R) 5.5%
    • WI-07: Tom Tiffany (R) 5.4%
    • KS-01: Tracey Mann (R) 5.0%
    • WI-08: Tony Wied (R) 4.9%
    • WI-06: Glenn Grothman (R) 4.4%
    • WI-03: Derrick Van Orden (R) 4.4%
    • WI-05: Scott Fitzgerald (R) 4.1%
    • WI-04: Gwen Moore (D) 4.1%
    • WI-01: Bryan Steil (R) 4.0%
    • WI-02: Mark Pocan (D) 3.9%

Fascinatingly, all twelve of them are in either Wisconsin or Kansas...the polar opposite of their fellow non-expansion state Florida. The only thing I can think of is that WI & KS are the only 2 non-expansion states located in the Midwest; I presume it has to do with the different economic conditions there vs. Florida? Huh.

In any event, I'm sure there's a lot of other fascinating data nuggets that folks will pick up as they poke around the spreadsheet. Feel free to let me know what you find!

Medicaid Expansion
Basic Health Plan
QHPs

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