As repeal efforts get underway for the Affordable Care Act, Republicans continue to debate over what should and shouldn’t be included in the new healthcare system. Repeal is easy enough using budget reconciliation, but replacing legislation like the ACA won’t be easy, legally or politically. Politicians are taking the lead from other politicians in crafting what they believe to be a better alternative to Obamacare. But one viewpoint that seems to have been dropped by the wayside is the one that got Trump elected in the first place. Men and women in the Rust Belt – an area spanning the upper Northeast and the Midwest – helped propel Trump to victory in the 2016 election. These working-class individuals have strong opinions about what they want out of a healthcare plan, but some of their ideas stand in direct opposition to what’s being proposed on Capitol Hill at the moment.
A Shift in Ideology
Rust Belt voters have typically supported Democratic candidates, but this season’s election cycle saw a shift in ideology for many people living in blue states. Disillusioned by some of the lofty promises that fell short after the implementation of Obamacare, these disaffected voters rallied to Trump’s equally lofty promises. His reassurance that nobody knew healthcare better than he did seemed to resonate with blue-collar workers, who helped him secure both the Republican nomination and the White House.
Voters in the Rust Belt don’t have any strong convictions about supporting conservative values. They simply want to find workable solutions to provide themselves and their families with reliable, affordable health care. These “Trump Republicans” may be in for a surprise. Once hardcore, rightwing leaders take office in January, the people who voted for Trump could find themselves even further disillusioned by the political process. Trump and his Republican peers in Congress could stand to lose support on both sides of the political aisle if their proposals don’t deliver on promises made during the campaign.
Checking in with Voters
Michigan, Pennsylvania, and Ohio were among the Rust Belt states that Trump flipped from Democrat to Republican in the 2016 election. In December, The Kaiser Family Foundation assembled two focus groups in three cities in key swing states: Grand Rapids, MI; Columbus, Ohio; and New Cumberland, PA. Each city had a focus group of Trump supporters on Medicaid and another group comprised of Trump supporters enrolled in ACA marketplace plans. Notable similarities emerged in the responses gleaned from these focus groups, regardless of whether participants had Medicaid coverage or were enrolled in the Affordable Care Act. Majorities of both groups stressed the need for affordable coverage and expected Trump to solve health cost problems. Many expressed anxiety about the future of health care.
Focus group participants raised specific concerns about the future of healthcare in America, including the rising cost of co-pays, prescriptions, premiums and deductibles. They also expressed concern or dissatisfaction about:
- Which services were and were not covered under their health plans
- Unexpected medical bills, primarily for services they thought were covered
- Having to change plans and doctors from year to year in order to keep costs down
- Big Pharma and health insurance companies in general, who many blame entirely for the failings of the healthcare industry as a whole
People enrolled in marketplace plans also told Kaiser that they didn’t appreciate the fact that Medicaid enrollees appeared to be getting better, more comprehensive coverage at lower costs than what marketplace enrollees could get. Most widespread survey results indicate that ACA marketplace enrollees are generally satisfied with their coverage. Kaiser focus group participants were a notable exception.
Questions about Trump’s Approach
Despite dissatisfaction with the way things are, participants also had concerns about several Republican replacement proposals. Tax-preferred health savings accounts, age-based tax credits and high-deductible catastrophic coverage are not popular ideas among the working class, most likely because these features would not be practical for millions of Americans. Trump’s nominee for secretary of health and human services, Tom Price, is among those pushing for such measures, which has caused concern among Trump voters who expected a more populist approach to healthcare reform.
One area in particular that the focus groups objected to was delaying the “replace” portion of Trump’s repeal-and-replace promise. Paul Ryan and others in Congress have proposed repealing the ACA immediately but delaying replacement until an appropriate plan can be implemented. Such an approach could leave the marketplaces to flounder. Trump voters did, however, expect Trump to use his business experience to avoid any kind of impending disaster. People who didn’t have health insurance before Obamacare took effect don’t want to go back to being uncovered. Medicaid participants expressed the least amount of dissatisfaction with their healthcare coverage.
Trump supporters view the individual mandate under the ACA as an unfavorable intrusion into personal freedoms, and those in the focus groups were confident that Trump would find a less invasive way of keeping coverage affordable for people with pre-existing conditions. Rather than agree that all U.S. citizens should share the burden of healthcare costs, group members were willing to embrace pre-ACA plans that cost less for themselves and their families even if it would mean higher costs for people with greater medical care needs. The focus groups also agreed on several top priorities, including:
- Regulated drug networks
- Increased access to affordable medications
- Elimination of unexpected medical bills
- Lower out-of-pocket costs for healthcare
Trump supporters also want assurance that their network could provide them with adequate coverage. They’d also like for plans to be less complex and confusing. Even though the ACA sought to make coverage clearer, people are still having trouble understanding what they’re buying and how their plans really work.
Challenges Going Forward
Since proposed Republican health plans may actually increase deductibles, and GOP lawmakers would be reluctant to raise taxes to pay for higher subsidies, Trump voters’ demands may go unmet by the GOP-controlled Congress. How Trump and his followers plan to deal with the disparity between their wish list and the Republican party’s probable unwillingness to deliver acceptable solutions remains to be seen. Some state governments are stepping up to combat the issue of surprise medical bills on a statewide level.
Though Trump and many of his supporters have jumped on the Republican-led bandwagon to repeal Obamacare, there doesn’t seem to be much consensus on the most effective path to replacing this important piece of legislation. In Congressional discussions of the topic, little has been mentioned about some of the key concerns expressed by the Kaiser focus groups. Working-class Trump supporters are likely to withhold their support for any plan that doesn’t address their list of top priorities. If Trump and Republican legislators fail to deliver an affordable, uncomplicated, and effective healthcare plan, they could become very unpopular with those who voted to put them into office.