The American Health Care Act falls far short of repealing and replacing the Affordable Care Act, but there are some big potential changes. (Daron Taylor/The Washington Post)

Last week, House Minority Leader Nancy Pelosi (D-Calif.) made a bold assertion about the Republican-backed bill meant to replace the Affordable Care Act, better known as Obamacare.

“Sadly, the people who will lose care if the Republican plan were to prevail, which I doubt it will, are people who voted for Donald Trump, many of them,” Pelosi said. “And you know where the benefits are going to go for all that $600 billion? Largely blue states. You know where some of the benefits will be lost? Largely in red areas.”

“It’s a very sad transfer of wealth,” she added. “But it’s an ideological thing with the Republicans, and I don’t think the president really knows what he’s talking about.”

As we’ve noted before, this framework, at least up to the part where Pelosi disparages President Trump, is accurate.

Any number of outside groups — and, now, the Congressional Budget Office — have looked at the likely effects of the Republican plan, known as the American Health Care Act. One of those groups was the Center on Budget and Policy Priorities, which broke out how tax credits for purchasing insurance would rise or fall in states if the AHCA were to replace Obamacare. According to the CBPP’s data (which excluded 11 states that operate their own exchanges), the average reduction in tax credits in states that backed Democratic presidential candidate Hillary Clinton in 2016 would be about $1,100 annually. The average for states that backed Trump? A decline of more than twice as much, $2,700. Even excluding Alaska, where the effects would be dramatically larger, the average would still be about $2,450.


Not only that, but there’s a loose correlation between how strongly a state backed Trump and how big the cut to residents’ tax credits would be. The redder the state, broadly speaking, the deeper the cut.


Two states would see a net increase in tax credits. Both backed Clinton.

Our previous analysis of the effects of the switch to the AHCA relied on data from the Kaiser Family Foundation, which looked at the likely change in each county and offered a broad demographic analysis of the law’s effects. On Monday, it released county-by-county results, allowing us to take a closer look at the politics of the replacement proposal.

Overall, the same pattern emerges. Counties that backed Trump in 2016 always see a bigger reduction in tax credits on average than those that backed Clinton — until the income level for an individual hits $75,000.


To determine the possible overall effects of the AHCA in each county, we took Census Bureau data on the number of families living in each income range addressed by KFF. (We looked at data for 40-year-olds instead of 60-year-olds, if you’re curious.) We then applied the likely change in tax credits to each of those families and averaged the result in each county. If you compare that average to the results in each county, the correlation is only slightly weaker than within states. The mass of counties that voted Republican would generally see lower tax credits than the blue counties.


On this metric — which looks only at a subset of families in each county, mind you — counties that backed Clinton see an average net reduction of less than half what counties that backed Trump do. (The average for Clinton counties is that families in those income brackets would collectively average a $1,500 decrease. The average decrease for Trump counties would be $3,300.)

To Pelosi’s point, though, a lot of the counties that backed Clinton are much larger than the ones that backed Trump. If we overlay estimates calculated by ACASignups.net‘s Charles Gaba of how many people in each county currently receive subsidized policies, the weight of the chart shifts.


Some of this is a function of those blue counties often having a lot of families who earn higher incomes and, therefore, would fare better under the Republican tax credit proposal, according to the Kaiser Family Foundation. Those families are less likely to currently have subsidized policies they obtained through a public exchange.

There’s another way in which the AHCA would benefit those wealthier counties that backed Clinton. As Bloomberg reports, the repeal of a Medicare tax on high-income individuals would disproportionately benefit them as well.

Older Americans would fare worse under the AHCA. So would more rural areas and places that more heavily backed Trump for president. In one sense, it’s impressive that the Republican plan would advocate for a change that affected its base negatively.

This does circle back to Pelosi’s other point, though. Does Trump realize that the proposal created by congressional Republicans would likely have disproportionately negative effects on his own base?