How the voters thought about health care

The election is over and Donald Trump, to the surprise of most people (including, apparently, the Trump campaign team) will be the next president of the United States. Although this will have profound consequences for health policy, it does not appear that health care issues were a major factor in determining the outcome.

Certainly, health reform never became the political plus that proponents hoped it would be, but neither was it the albatross that critics claim it was. Opinions about the health care law have remained essentially stable and dominated by party identity since the Affordable Care Act (ACA) was passed. In addition, health care remained a second-tier issue throughout the campaign.

According to analysis by Robert Blendon at the T. H. Chan Harvard School of Public Health, a single core question – whether you believe the federal government should play a significant role in ensuring that people have access to coverage – was strongly associated with both your attitude toward the ACA and toward the presidential candidates. People remain largely uninformed about the details of the ACA. Their attitudes are driven by values, not the specific provisions of the law (many of which remain broadly popular).

One interesting correlation between health and voting was discovered by staff at The Economist. Counties with high rates of obesity, diabetes and heavy drinking and low rates of physical activity went heavily for Donald Trump. These voters, hit hard by deindustrialization and not benefiting from a rebounding economy, made up a small percentage of Trump voters. But they may have provided him with his margin of victory in key battleground states.

Turning from the electorate to policy that may flow from the outcome, the Affordable Care Act is a law that has had nine lives. But in the wake of Trump’s victory it is now threatened like never before. Truly, the fate of the ACA per se is neither here nor there. The urgent question that confronts us now is how to preserve the coverage gains and financial protections that millions of people now enjoy. Twenty-two million people could lose their coverage outright if the ACA is repealed, but that is just the tip of the iceberg.

The ACA provides important benefits to millions of people who never even glanced at Healthcare.gov, such as protections against pre-existing condition exclusions and charging sick people more for their coverage, limits on rates charged to older adults, the bans on lifetime benefit caps and charging women more than men, and better access to preventive health services. All of these protections are at risk if the ACA is unraveled.

And the damage doesn’t stop there. House Republicans have put forward the outline of a plan that would undermine coverage for millions of children, seniors and people with disabilities who depend on Medicaid. They have also proposed reducing benefits and increasing costs for Medicare beneficiaries.

 

Would you buy a used car from these men (sight unseen)?

For six years, Republicans have been talking about repeal and replace, but they have yet to coalesce around a replacement plan. Now Republican leaders in the House and Senate are pursuing a strategy of repeal now and replace later. They are proposing to light a fuse by repealing essential components of the ACA but delaying the effective date. Essentially, they’re saying, “Trust us we’ll come up with something good to replace it before the bomb goes off.”

But there is nothing in the past six years that should give people any confidence that Republicans can pull it off. A large cohort of Republican voters (and presumably their representatives) would be content to repeal the ACA and replace it with nothing. In addition, the overall intent of the Ryan blueprint, much of which is also reflected in Trump’s policy agenda, seems to be to use health care programs as a piggybank to pay for (wait for it) tax cuts for the wealthy and increased military spending.

There is also a great likelihood that the “bomb” will go off early. Even if there is a delay in cutting funding for premium tax credits, insurers are less likely to participate. And the more uncertainty there is about the shape of any future system, the less likely healthy people are to sign up for coverage. This will drive premiums up and enrollment down.

 

Meet the real Donald Trump

President-elect Trump’s position on these issues is unclear. During the campaign, Trump said a lot about protecting Medicare (and Medicaid). While he was clear about repealing the ACA, he often spoke about making sure people had better, more affordable coverage. Cynics might think that he was about as sincere as a snake oil salesman promising miracle cures. Certainly his recent embrace of “Medicaid flexibility” and Medicare modernization,” both often code words for program cuts, is cause for concern. An early tip off as to his true intent will come as he positions himself relative to Congressional plans to repeal without having a replacement plan ready.

Once funding for premium tax credits and Medicaid expansion is repealed, it is no longer available to help finance a replacement plan. This means that whatever comes next will be much stingier than would be the case were that funding still available. Reduced funding will not only undermine coverage for the newly insured, it will also financially destabilize many providers and result in a large cost-shift to state government.

However, it appears that the incoming Trump administration is on board with the Congressional scheme making his promises to protect Medicare and Medicaid and replace the ACA with “something terrific” much harder to realize. Because separating repeal from replace would be so damaging, it is important to mobilize now against this approach. Republican leaders are hoping to hold a repeal vote in January in order to present a repeal bill on or near Trump’s first day in office. Much of the health care community, including Community Catalyst, is now focused on opposing this plan to repeal the ACA without a replacement.

 

We the People

Donald Trump was elected by a minority of the electorate. Most people do not want to see the ACA repealed. They don’t want to go back to the days when insurance companies could discriminate against people based on their health status. They don’t want to cut health benefits for children, seniors, or people with disabilities. The challenge now is to ensure that the views of the minority do not undermine hard-won health security for millions of Americans.

With the musical “Hamilton” putting the American Revolution into popular consciousness, a couple of random bits of Revolutionary War trivia have recently popped into my mind. As the reality of Trump’s upset victory sank in, I recalled the song that the British played as they surrendered to Washington at Yorktown—“The World Turned Upside Down.” But now, as the shock has worn off, I recall instead the words of John Paul Jones (the Naval hero, not the Led Zeppelin bass player): “I (we) have not yet begun to fight.”