When the Trump administration set about chipping away at the Affordable Care Act immediately upon taking office, it was widely predicted that the policy changes and outreach cuts would create the biggest hurdles for the groups most likely to vote Democratic — including young people, people of color, and the poor. Many months later, new reports on the national uninsured rate suggest the opposite may be true: the Trump administration’s health care agenda is whacking red states hardest.

A new report from National Center for Health Statistics (NCHS) released this week found that while the overall uninsured rate held relatively steady over the course of 2017 the gap between (largely Democratic-controlled) states that expanded Medicaid and the (largely Republican) states that have yet to do so is the widest it has been since the implementation of the ACA. By the end of the Trump administration’s first year in power, the uninsured rate in non-expansion states was more than twice the rate in states that accepted federal funding to expand Medicaid under Obamacare.

Because the report only covers the national rate through 2017 — and thus does not show the impact of the Trump administration’s decision to repeal the individual mandate, allow the sale of skimpy, short-term plans, and give states a green light to implement Medicaid work requirements — the disparity is almost certain to get worse.

A report released by the Commonwealth Foundation in early May provides additional evidence that the Trump administration’s health care policies and rhetoric are taking a toll on GOP voters. The analysts found that “the uninsured rate among adults who identify as Republicans jumped from 7.9 percent in 2016 to 13.9 percent in the first quarter of 2018. The uninsured rate among those who identify as Democrats, on the other hand, held steady at 9.1 percent over that same time period. Southern states, which are largely Republican-controlled, also showed a marked increase in their uninsured rates — from 16 percent in 2016 to over 20 percent in early 2018. These states had a higher uninsured rate than states in the Northeast, Midwest, and West.

﻿﻿﻿

As with everything in the health care space, many different factors likely contributed to this disparate impact.

Republican voters may have been more susceptible to President Trump and GOP lawmakers’ rhetoric declaring the ACA “dead” and “imploding,” releasing official government videos blasting Obamacare, and falsely asserting that the individual mandate penalty has already been abolished when it in fact is in effect through 2018.

Majority-Republican states were also less likely to invest their own dollars in ACA outreach during the 2017 open enrollment period, after the Trump administration gutted its outreach funding by 90 percent.

Going forward, the health care gap between Democrats and Republicans is set to widen further.

Four states with GOP governors — Kentucky, Indiana, Arkansas, and New Hampshire — have already won federal permission to impose work requirements and other restrictions on their Medicaid programs, policies predicted to strip hundreds of thousands of people of their coverage and drive the uninsured rate higher in those states. Many more states have submitted requests to HHS for permission to implement similar rules.

In a tacit acknowledgement that these policies are set to hit many of their own constituents, Republican lawmakers in a handful of these states have created carve-outs that would exempt some rural, white, conservative voters from the work requirements while allowing them to take effect in low-income urban neighborhoods of color. By basing the exemption on the unemployment rate in each county, these nominally politically and racially neutral rules would protect rural, majority-white counties while leaving out residents of high-unemployment cities with wealthy suburbs.

This week, after many legal experts noted their plan could violate federal anti-discrimination laws, Michigan backed away from the scheme. But a similar county-based carve-out is set to take effect in Kentucky this summer, and one in Ohio that would have a disparate racial impact is awaiting federal approval.

Many health care experts have pointed out, however, that such exemptions would only shield a small percentage of the GOP base from the brunt of the work requirements, and that hundreds of thousands of low-income people in those states — Democrats and Republicans, urban and rural residents — are at risk of becoming uninsured.

At the same time, states with Democratic majorities are exploring policies to further reduce their uninsured rates. With the federal individual mandate penalty set to disappear in 2019, Maryland, Hawaii, New Jersey, Vermont, and the District of Columbia are considering adopting their own state-based mandates in an attempt to boost insurance coverage in those states. Massachusetts and Vermont also plan to provide more generous subsidies for people in marketplace plans. Virginia — a state that saw a blue wave in the 2017 election — is right on the cusp of expanding Medicaid to cover 400,000 more people.

With the Trump administration vowing to allow more state flexibility on health care rules going forward, including the waiver of rules governing both Medicaid and the ACA, the political and geographic divide will likely widen in the years to come.