Up to 40% of low-income adults living in Republican states where Medicaid coverage has been expanded say that the Affordable Care Act (ACA) has made a positive difference in their lives, according to an analysis published in The New England Journal of Medicine.

“Even in the most conservative region in the country, many people report substantial benefits from the law [ACA] and are willing to directly credit the ACA for those changes,” write Benjamin Sommers, MD, PhD, and Arnold Epstein, MD, from the Department of Health Policy and Management at Harvard T H Chan School of Public Health in Boston, Massachusetts.

The authors note that a 2016 report by the White House Council of Economic Advisers found that the ACA — in particular, the Medicaid expansion component — increased access to primary care and treatment for chronic illness, reduced hospital spending by at least $10 billion, and saved approximately 24,000 lives each year, among other impacts. Nevertheless, Medicaid expansion will likely be one of the first items repealed by the new Congress, they write.

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To understand how Medicaid expansion has affected health-insurance coverage, utilization and attitudes towards health-care reform in Republican states, Dr Sommers and Dr Epstein spent four years conducting a validated telephone survey of low-income adults aged 19-64 from Arkansas, Kentucky, Louisiana and Texas, all of which are Republican states. Arkansas, Kentucky and Louisiana have expanded Medicaid, but Texas does not.

The researchers found that Medicaid expansion in the three states studied that have it has substantially improved access to care, affordability, chronic-disease management and self-reported health. Furthermore, in the three expansion states, roughly 30% to 40% of respondents said that they were helped by the law, compared to approximately 15% who said that they were hurt by it. This was in contrast to Texas, where 15% said that they were helped by the law, and more than 20% said that they were hurt by it.

When the researchers analyzed their data according to race, they found that even reliably conservative groups in Kentucky and Arkansas — “Southern whites” — reported benefiting from the law more than being hurt by it.

The strongest predictors of positive attitude towards the ACA were living in a state with Medicaid expansion and having Medicaid or ACA marketplace coverage.

“The question is not whether many Americans — even those in thoroughly red states — have benefited from the ACA, but whether that will be enough to save it,” the authors caution.


Sommers BD, Epstein AM. “Red-State Medicaid Expansions — Achilles’ Heel of ACA Repeal?” The New England Journal of Medicine. 2017;376(6): e7. doi: 10.1056/NEJMp1700156

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