What’s not so easy to see is how the Republican alternatives being discussed on Capitol Hill are supposed to make these problems better. They might even make things worse overall.
Those are the main takeaways from a public opinion report that the Henry J. Kaiser Family Foundation released on Wednesday. The basis for the report is a series of three focus groups with Trump voters that Kaiser conducted, back in December, in the politically critical states of Michigan, Ohio and Pennsylvania.
All of the participants had insurance through the Affordable Care Act ― in other words, they’d either purchased private insurance through one of the law’s exchanges, or they’d enrolled in newly expanded Medicaid programs.
The report includes a written summary of findings as well as a six-minute video with excerpts from the sessions. It should be of particular interest at the White House, where Trump and his aides must decide how hard to push for full repeal and replacement ― and how closely to follow the lead of the congressional Republicans drawing up legislation.
Kaiser’s researchers note that the participants are not necessarily representative ― of Trump voters, of Affordable Care Act users or of the population as a whole. And so, for instance, frustration with the quality of plans was a dominant theme among people buying coverage through the exchanges, even though surveys have found that a majority of people buying those plans are satisfied.
But the focus group sentiments are consistent with what any reporter covering health care has heard from time to time over the past few years, and they clearly reflect the feelings of some significant number of people. That’s particularly true of the criticisms that users of exchange plans made about high out-of-pocket costs.
An Ohio participant named Deborah (the report identifies participants by first name only) explained that, in order to keep premiums affordable, she had to go with a plan that came with a lot of cost-sharing.
“It’s an extremely high deductible,” the report quotes Deborah as saying. “I can’t even tell you what it is because I purposely do not go to the doctor because I can’t afford it. I have insurance and I don’t use it.”
Shari, from Pennsylvania, said that her plan left her exposed to huge bills for her prescription drugs, forcing her to make some difficult decisions. “You have to choose, do I pay my mortgage or do I pay the $800 medical bill that just came in the mail or do I pay for my medications that can be life sustaining or do I eat this week?”
It’s an extremely high deductible... I can’t even tell you what it is because I purposely do not go to the doctor because I can’t afford it. Deborah, from Ohio
Another common theme was confusion over coverage and networks, and the possibility of getting care only to discover later that it cost more than expected.
But some people buying exchange coverage felt better about their plans. “I think in all honesty it’s working well,” said a woman from Pennsylvania named Amy. “I mean, we’re very fortunate too that we don’t use the doctor very often... [My coverage] is, I can’t believe I’m going to say this, more affordable this year than it was last year.”
And even some of those unhappy with what they’d gotten from Obamacare’s exchanges seemed inclined to either keep and improve it, or to replace it with something better. And by “better,” they meant something that would alleviate the costs they face now.
This is where things get tricky for Republicans. While party leaders have yet to coalesce around a single proposal, they’re mostly talking about the same set of reforms ― allowing insurers to vary premiums more based on age or health, making it more difficult for people with pre-existing conditions to get coverage, reducing requirements on what insurance covers and reducing what the government spends on financial aid. Republicans would also nix the law’s individual mandate, which imposes a financial penalty on people who decline to get insurance.
Those changes could work out well for some people ― in particular, for younger and healthier people who currently have to pay higher premiums because insurers have to cover everybody, and include expensive services that only a minority of people use.
But the net result, inevitably, would be more exposure to high medical bills in some form or another. And the burden would fall more directly on those whom the Affordable Care Act helps most ― namely, older and sicker people, and people whose incomes presently qualify them for extensive financial help.
Our out-of-pocket and deductible costs shouldn’t bankrupt us, and preventive care and tests should be low cost. Suzanne, from Ohio
Such a shift might please the focus group participants like Scott, from Michigan, who questioned why healthy people should have to subsidize the unhealthy. “I’ve got to share in everybody else’s cost,” he said. “I may not have the condition, but other people do, and I’m still paying for it.”
But Julia, another Michigan consumer, warned that imposing more costs on people with medical conditions could hurt those people and their families. “I have a little different outlook now than I used to because of my son,” she explained. “He’s got a condition that’s going to last him all of his life now, so I want him to be able to get insurance when he becomes a working adult. I think that’s important.”
Suzanne, an Ohio participant, said she would like to see the health care system provide everybody with both low premiums and low deductibles ― something that sounds, again, more like the Affordable Care Act than what Republicans would put in its place. “Every person should have access to insurance at a reasonable price,” Suzanne said. “Our out-of-pocket and deductible costs shouldn’t bankrupt us, and preventive care and tests should be low cost.”
Some participants even endorsed adopting a single-payer system, like the kind Sen. Bernie Sanders (I-Vt.) proposed during the Democratic presidential nomination campaign. ”I’m far from a socialist, but I think the only answer is a single-payer thing in this particular instance,” Randy, from Ohio, said. “People need to go to the doctor when they need to go to the doctor, and they don’t need to worry so much about it that they get sicker.”
One other big complication for Republicans is the law’s Medicaid expansion, which Republicans have said they want to roll back, even if it must be done gradually. GOP leaders have tried to justify this in part by saying the coverage is lousy.
This would come as news to the focus group participants who actually have Medicaid and who are, consistent with the available polling, very grateful for it.
I’m insured for the first time in probably 15 years through Medicaid. Susan, from Michigan
“I’m insured for the first time in probably 15 years through Medicaid,” said Susan, from Michigan. “It’s nice you can have a provider, and you have a connection, and you can go in and get some fairly decent healthcare.”
Dawn, also from Michigan, said: “I was hurt at a job, and for the last five years I’ve been doing the battle. I had no insurance and couldn’t work... Without Obamacare coming through, and opening up the Medicaid rolls... I’ve had four surgeries in two years, and I’m getting back on my feet.”
The idea that Trump voters might support parts of the Affordable Care Act, or that they might even prefer a system that is more generous rather than less, should not be surprising. Reporters like The Atlantic’s Olga Kazhan and Vox’s Sarah Kliff found basically the same thing when they conducted extensive interviews with Trump voters after the election.
Trump, meanwhile, has repeatedly promised that his alternative to Obamacare will mean “great health care for much less money” and “insurance for everybody,” and that ”everybody’s going to be taken care of much better than they’re taken care of now.”
The plans that Capitol Hill Republicans are cooking up don’t live up to those vows. The big questions going forward are whether Trump realizes this and, if so, whether he intends to do anything about it.