The sense of urgency Republicans feel about taking immediate steps to repeal Obamacare — even if those steps are initially symbolic, and plagued by the GOP’s own confusion over what comes next — is in part a legitimate response to the belief that the voters most important to them really, really hate the Affordable Care Act. And there is abundant evidence the white working-class voters whose sudden tilt toward the GOP in Rust Belt battleground states rewarded Donald Trump with the presidency and helped Republicans hang on to Congress really do dislike the Affordable Care Act disproportionately.
Here’s the problem, though: What these key Trump voters most dislike about life under the Affordable Care Act will get even worse under any plausible GOP replacement plan.
As the Kaiser Family Foundation’s Drew Altman reports in a New York Times op-ed, focus groups among Trump-voting Rust Belt white working-class voters who have obtained health insurance through Obamacare — i.e., those most familiar with the ACA — show a very consistent pattern:
They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered … When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief.
Here’s what they’d rather have:
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs.
The trouble is, of course, that keeping out-of-pocket costs high and letting market forces control drug prices are fundamental principles of conservative health-care policy, which have been reflected in every Republican health-care proposal for years. To conservative policy thinkers, overutilization of health services, encouraged by government subsidies and regulations (along with “defensive medicine” caused by consumer lawsuits), is the primary source of rising health-care prices and virtually every sin of the health-care system.
So when Republican policymakers talk about “personal responsibility” being critical to heath reform, that’s code for making sure Americans feel some pain every single time they access health services. The way you do that is by increasing exposure to out-of-pocket costs via premiums, deductibles, copays, and exposure to big bills if you don’t strictly obey your insurance company’s arcane rules. You can sugarcoat this a bit by offering a tax subsidy for personal savings so that you have more money for those out-of-pocket expenses; that’s the basic point of the Health Savings Account idea, a feature of every conservative health-care proposal since time immemorial, and a particular favorite of Vice President-elect Mike Pence. Indeed, the goal many Republicans have long embraced is a system where everybody gets a high-deductible insurance policy covering catastrophic health conditions, with no insurance at all for routine services, which consumers would handle themselves with some help from an HSA.
But if the KFF research is correct, it’s the routine services that Trump’s white working-class base thinks they should have access to without emptying their wallets or being hassled by an insurance company. That is partly why so many of these people exhibit resentment toward Medicaid beneficiaries who don’t have the same problems in obtaining routine services. Given the chance, of course, Republican pols would introduce “personal responsibility” requirements to Medicaid as well, as GOP governors like Mike Pence have shown in the deals they’ve cut with the Obama administration to expand eligibility in exchange for generous new federal dollars. In the ideal GOP world, everyone would be paying more for routine services — even the very wealthy, who would have to shell out large premiums for concierge services to keep them from rubbing elbows with the hoi polloi in waiting rooms.
So will white working-class Trump voters realize this conflict between their views and those of their party before an Obamacare replacement plan goes into effect? Nobody knows. But it’s not like they won’t be paying attention. As Ron Brownstein notes, the savage antipathy these folks feel for Obamacare is based on an intimate familiarity with the law, because so many of them receive health insurance via the ACA:
[I]n practice millions of blue-collar whites have gained coverage under the law, particularly in states critical to the Republican electoral map. Using census data, the Urban Institute recently calculated that from 2010 through 2015, more non-college-educated whites gained coverage than college-educated whites and minorities combined in all five of the key Rustbelt states that flipped from Obama in 2012 to Trump in 2016: Iowa, Ohio, Michigan, Wisconsin, and Pennsylvania. Whites without a college degree also represented a majority of those gaining coverage under the law in core Trump states like Indiana, West Virginia, Kentucky, Arkansas, and Oklahoma.
These states often saw enormous reductions in the number of uninsured working-class whites: about 40 percent in Indiana, Pennsylvania, and Wisconsin; roughly 50 percent in Ohio, Iowa, and Michigan; and 60 percent in West Virginia and Kentucky.
So if they lose insurance altogether or are forced into new health-insurance plans that double-down on the very features they hate about Obamacare, these key Trump voters will not be very happy. And Trump tweets about how “terrific” the post-Obamacare world of health-care policy has become won’t help.