The House of Representatives will take its 37th vote to repeal the Affordable Care Act — or it might be the 38th. With more than three dozen votes cast, it's difficult to keep track.

It's easy to write off these votes as pure political spectacle with no substantial meeting. Members of Congress can tell their constituents that they voted to repeal Obamacare and move on to other issues.

But there's actually a compelling case on the other side, that these actions do really matter in a substantive way. This slew of three dozen repeal votes have changed both how the Affordable Care Act works and how the public perceives it.

Last month, the Kaiser Family Foundation polled Americans on whether the Affordable Care Act is still law. Twelve percent of Americans — that's about one in eight people — think that Congress repealed the Affordable Care Act. Another 23 percent aren't sure or refused to answer the question.

Congress' repeal votes get media attention and coverage, which probably explains where these numbers come from. After hearing so much about congressional repeal, it's hard to blame Americans who think that the efforts have succeeded.

The uncertainty that these repeal votes have created can have real consequences for the Affordable Care Act. There's fairly comprehensive literature that suggests that when regulations seem like they might get repealed, people resist them aggressively. When the new restriction appears to be set in stone, however, the reaction seems to be rationalization: Trying to think through why the regulation isn't, in fact, all that bad.

There was a great study on this phenomena last year that used speed limits as a restriction. It found that research subjects were generally okay with the new regulation, unless they were told there was a chance the city council would repeal it. Add that information in, and opinions about the law became significantly more negative.

In the course of nearly 40 repeal votes, Congress has also managed to change the Affordable Care Act in some substantive ways. It repealed a small-business tax reporting requirement that legislators in both parties derided as onerous. Congress changed the way income gets counted under the Affordable Care Act in determining who receives a tax subsidy to purchase health insurance coverage.

Congress has cut off funding to a program that was meant to fund new, nonprofit health plans in all states. It  also cut into the Prevention and Public Health Fund, which pays for everything from primary care residencies to healthy corner store programs. 

These are actual changes to the Affordable Care Act which have not dismantled the law but have certainly effected what the final product will look like. They have also bolstered the stance of the Republican Party as decidedly anti-Obamacare, a position that has had a marked impact on the health law's state-level implementation.

The majority of states are either not expanding Medicaid or leaning against the idea. "The outlook for the Medicaid expansion is bleak," Avalere's Caroline Pearson tweeted a few weeks back. She included a picture of this map, showing the program's prospects:

Since late April, when this map was created, Florida has opted not to expand Medicaid, whereas West Virginia Gov. Earl Ray Tomblin has endorsed the policy option.

Most states have also decided against running their own health exchanges, which means a bigger workload for the federal government, which will now have to step in and create those marketplaces.

It's easy to write off the repeal votes as inconsequential but, from a policy standpoint they're not. They've effected what the Affordable Care Act looks like nationally and locally in ways that will matter for years to come.