Despite the recent failure by the GOP to repeal and replace the Affordable Care Act (aka Obamacare), two-thirds of GOP voters want them to continue to try, and more than half of those want the GOP to work with Democrats on a solution. The remaining third say they want the GOP to abandon efforts to repeal. The Republican Congress seems to be listening to that third, as they attempt to move on to tax cuts and budget issues. No matter what the polls say, however, come Open Enrollment time in November, when premiums increase as they are predicted to do, it’s likely there will be pressure from the GOP base to try again.
What these polls don’t always differentiate is voters who actually have to buy their insurance on the ACA marketplaces from those who have insurance through their work, get it via Medicaid, or are over 65 and have guaranteed coverage through Medicare. Most of these voters get lumped together in aggregate numbers that don’t really tell the whole story.
Surprisingly, only four percent of Trump supporters actually purchased their health insurance through the marketplaces last year, according to a study by the Kaiser Family Foundation and data from the Cooperative Congressional Election study. Yet if you ask Trump voters what they think about the ACA, most have continued to say they oppose it and support its repeal. The remaining 95+ percent who do not have to buy on the individual market probably don’t even know about the benefits the ACA added to their insurance —limits on what they would ever have to pay out of pocket, free preventive care, better prescription drug coverage under Medicare, ban on pre-existing conditions, etc. With increased costs and the rhetoric from the party relentlessly pushing the message that it is a terrible law and is imploding, any benefits gained got lost in the debate.
In December 2016, a series of Kaiser Family Foundation focus groups interviewed Trump voters from Michigan, Pennsylvania and Ohio –voters who supported Trump but bought insurance through the marketplaces last year. These focus groups did not claim to necessarily represent the general population of Trump supporters, but they did zero in on those supporters who were most affected by the ACA. And here is where the analysis gets interesting. The Kaiser focus groups found that while many of these Trump voters were relieved to have insurance coverage, most were quite surprised by the reality of the costs and the complexity once they became enrolled. They intensely disliked the high deductibles in the lower cost plans (i.e. Bronze or Silver plans), the surprisingly high costs of prescription drugs, and the fact that people were being “forced” to buy insurance (i.e. the individual mandate) or be penalized if they didn’t. And they didn’t buy the favorite GOP idea of Health Savings accounts at all, because of the high deductibles. They also found the insurance terms complicated and confusing.
The Kaiser focus groups were conducted before the most recent replacement plan debacle in Congress. Initially, GOP voters who bought their insurance through the marketplaces supported the Republican replacement plans (the AHCA and the BCRA), even though they clearly would have the most to lose under these plans. “The voters hit the hardest — eligible for at least $5,000 less in tax credits under the Republican plan — supported Mr. Trump by a margin of 59 percent to 36 percent.” The support for these plans began to falter, however, as voters learned what it would really mean for them. Even Republicans began to hate these plans.
The President now recognizes that health care is not as simple as he thought. He made “repeal and replace” sound so easy, and Republican representatives didn’t bother to explain why it was not. House Republicans voted 217 to 20 for a replacement bill that even the President said was “mean.” And 43 Senate Republicans voted for a replacement bill that failed, 45 voted for a “partial replacement bill that failed, and 49 voted to support the “skinny replacement” bill that also failed. Most who voted for these replacement bills did so presumably because they believed their “base” understood and demanded that they do that.
Did GOP voters support repeal and replace simply because they didn’t understand the implications in their own lives? Were they just fooled by the easy slogans? Maybe. But we in the health policy community and the media share responsibility with legislators for the lack of support for bipartisan solutions. We have all let voters down by not explaining health insurance more clearly. We have utterly failed to speak English about why costs are so high, why it’s important to get healthy people into a “pool” to spread the costs around for those who do get sick, and how health insurance really works. (Don’t forget that Trump thought you could start paying $12 for health insurance in your 20s and take it out when you needed it! ) We have conflated “health care” with “health insurance”, promising great health care when we meant mediocre health insurance with limited doctor and hospital access. Those of us who support the ACA have ceded the debate to those who would demagogue it with easy answers.
In one of my Huff Post articles from 2010, I predicted that once the ACA took hold in people’s lives, they would support it more. (In fact, over 50 percent now support it.) I also outlined what I thought the Republicans would do if they could replace the ACA. To some degree, those predictions came true. But despite my minuscule efforts and thousands of other articles and tweets by so many over the years, people still don’t understand health insurance or the ACA or even what to do to make it all better. Now that we have a little breathing room to come up with some bipartisan “fixes”, it’s time to step up the education and the communication from both Republicans and Democrats. There are a lot of things we can do to fix the ACA—here and here and here if you are interested. But we need a much better effort to explain to all voters what needs to be done. If we don’t do that, the next cycle will attract the same pattern of support and opposition barely tethered to the reality of voters’ lives.