The Electoral Consequences of Roll Call Voting: Health Care and the 2018 Election


For years, Republicans in Congress promised to “repeal and replace” the Affordable Care Act. The results of the 2016 elections put them in position to take action on the seminal domestic policy achievement of outgoing President Barack Obama. Repeal efforts faced many obstacles, including angry constituents crowding town hall style meetings with Republican members. Many members faced a stark choice between voting with their constituents or voting with their party. We use data on the number of town halls held by members to analyze whether members who heard from upset constituents were more likely to oppose the repeal effort. Next, we utilize data on House primaries and the 2018 general election to test whether the member’s position on repeal had any effects on the member’s electoral success. We find clear evidence that member’s voting behavior on the health care repeal had electoral effects in the 2018 general election.

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  1. 1.

    Joseph Cao (R-LA) was the sole Republican to support the bill initially, but he voted “nay” on the final House vote.

  2. 2.

    Data from the Wesleyan Media Project,

  3. 3.

    This chant was clever as it was Rep. Joe Wilson who famously yelled “You Lie” at President Obama as he addressed a joint session of Congress to outline his plan for health care reform in 2009.

  4. 4.

    The dynamics of public opinion on the ACA have been somewhat bizarre from the outset of the law. The law itself has never been overwhelmingly popular and support/opposition for the law has been heavily structured by partisanship — Democrats have tended to favor the law, Republicans have tended to oppose it. However, many of the key components of the law such as the increased age limit for children to stay on their parents’ insurance plan, the expansion of covered preventive services, and the prohibition on excluding patients due to “pre-existing” medical conditions have been supported by bipartisan supermajorities in the public. See, “6 Charts About Public Opinion on the Affordable Care Act,”

  5. 5.

    Previous literature may have failed to find a connection between a legislator’s policy decisions and electoral accountability in part due to measurement error (Ansolabehere et al. 2008; Goren 2004).

  6. 6.

    It is also, of course, possible, that members who may choose to be unresponsive do so because they have elected to retire from Congress. For those seeking reelection, we can assess whether they faced a primary or general election challenge, changes in their vote share in each electoral stage, as well as constituency opinion and coverage loss in the district.

  7. 7.

  8. 8.

    We restrict our analysis to the in-person town hall events.

  9. 9.

    Rep. James Sensenbrenner (WI-5) is a clear outlier on this measure. He held 51 town halls between the opening of the 115th Congress and May 4, 2017.

  10. 10.

    This bill later failed in the Senate with John McCain offering a “thumbs down” along with a negative vote.

  11. 11.

    Scott, Dylan, “Trump’s health care bid puts moderate Republicans in an impossible situation,” Vox, May 1, 2017.

  12. 12.

    Districts with the greatest predicted coverage loss were in Florida, North Carolina and Texas, and the representatives of these districts span both political parties.

  13. 13.

    We also estimated this model as a multinominal logit, and the results were substantively similar.

  14. 14.

    Manchester, Julia “Ryan says he won’t do public town hall citing concerns over possible protests,” The Hill, July 7, 2017.

  15. 15.

    Nelson, Louis “GOP split on whether paid protestors are to blame for rowdy town halls,” Politico, February 23, 2017.

  16. 16.

    This variable indicates the total number of town halls held before May 4th. We also fit this model with a count of the number of town halls held between March 24th and May 4th and the results were substantively similar.

  17. 17.

    We also fit these models with a dichotomous dependent variable indicating whether or not a candidate with previous electoral experience or a “quality” challenger had emerged (Jacobson and Kernell 1983). The results were substantively similar, so we elected to use the measure for the number of candidates given the recent success of amateur candidates in primaries (Porter and Treul 2018).

  18. 18.

    These models exclude districts in Pennsylvania due to the redistricting that was required in that state for the 2018 election.

  19. 19.

    The next largest issue was taxes, at 14.7% of airings (Fowler et al. 2018).

  20. 20.

    We think that many of the Republicans who retired rather than seeking reelection in 2018 did so because they were facing a tough re-election campaign. Some of this was, no doubt, due to the underlying political dynamics of their district. A number of the retiring members, such as Ed Royce (CA-39), Darrell Issa (CA-49), Pete Sessions (TX-32) were in districts that had been won by Hillary Clinton in the 2016 presidential election. Others, we think, retired because they found it difficult, if not impossible, to maintain a sufficient level of party unity while being attuned to the views of their constituents. Rodney Frelinghuysen, who represented 11th district of New Jersey is an excellent example of this. He was in his first Congress as chair of powerful Committee on Appropriations, was relatively young for a member of Congress (age 72 in 2018), and came from a political family—both his father and great-grandfather were former members of Congress. Yet, he decided to retire rather that run for reelection in 2018. Why? We think his vote on the GOP tax bill that passed in December 2017 is instructive. Some districts in states such as New Jersey had large number of voters who would face higher effective federal tax rates as a result of the fact that that the tax bill limited the state and local income tax (SALT) deduction. Frelinghuysen noted this in his statement of opposition to the bill. In response, the Republican leadership threatened to take away his committee chairmanship because he was not a team player.

  21. 21.

    As discussed above, we chose to focus on health care as this was the predominate issue in 2017 and 2018. However, in an attempt to see if other votes had a similar effect on election success we found two more roll call votes in the 115th Congress that had corresponding questions posed to respondents on the CCES. These were the Russian sanctions bill and the tax bill. Neither of these is ideal for analysis due to lack of salience to voters. Additionally, the Russian sanctions bill passed 419-3 and the tax bill was complex and had myriad provisions, eventually passing mostly along party lines. We did, however, fit the model presented in Table 3 with these votes as well. The Russia vote drops out of the model because both members who voted against the party’s position won their reelection campaign. Our results for the vote on the tax bill are the opposite of what we would expect if members were defecting from the party’s position to shore up support with their constituents, as those members who voted for the tax bill were more likely to win reelection than were those who voted against it. Most of the Republican members who voted against the bill were from states such as New Jersey, New York, and California that have high state, local, and property taxes. This bill limited the ability of taxpayers to fully deduct these expenditure by putting in a cap of $10,000 on the so-called “SALT” deductions. Republican members who voted against this bill likely did so to prevent their constituents from feeling the effects of this change, but the results do not suggest that this helped them electorally.

  22. 22.

    We have replicated the analysis with the full repeal question and get very similar results.

  23. 23.

    Similarly to the additional votes we analyzed in Table 3 we fit the model presented in Table 4 with voter agreement with the House member on the Russian sanctions bill and the tax bill, as these were both asked about on the CCES. Respondents who report agreeing with their member’s position on the tax bill were more likely to report supporting that member in the general election, while those who report agreeing with their member on the Russia sanctions bill are less likely to report voting for the member in the 2018 general election. Once again, we see this as evidence of there being something different about health care, most likely how salient this particular issue was.

  24. 24.

    No party identification is the omitted category.

  25. 25.

    We also fit this model with presidential vote choice interacted with respondent party identification and with state fixed effects and got substantively similar results. We also fit this model with the respondent’s self-reported ideology and got substantively similar results.


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Correspondence to Jason M. Roberts.

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An earlier version of this paper was presented at the 2018 Annual Meeting of the Midwest Political Science Association. We thank Adam Cayton for helpful comments. Replication data are available at

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Bussing, A., Patton, W., Roberts, J.M. et al. The Electoral Consequences of Roll Call Voting: Health Care and the 2018 Election. Polit Behav (2020).

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  • Congress
  • Roll call voting
  • Health care
  • Elections