If Not Obamacare, Then What?

Trump supporters in southern Pennsylvania say the Affordable Care Act has been a letdown. Here’s what they’d like instead.

Supporters, including one in a replica Civil War hat, gather at a Trump campaign event in Gettysburg in October. (Jonathan Ernst / Reuters)

GETTYSBURG, Pa.—As her hair was styled at the Grace Kelly hair salon in this quaint tourist town, a middle-aged mother told me that she wants Obamacare gone, even though her 24-year-old son is still on her plan, thanks to an Obamacare provision that allows young adults to stay on their parents’ health insurance until the age of 26. (The woman asked that we not use her name because she’s worried about her privacy.)

In its place, she’d like to see a new law in which people pay for their insurance as a percentage of their income, so that everyone has some “skin in the game.” When I asked her if the Obamacare subsidies, which reimburse people making less than about $48,000 for a portion of their health-insurance premiums based on their income level, come close enough to this kind of system, she balked. “I do not like the Obamacare subsidies,” she said.

Thus goes yet another attempt to solve the health-care riddle of the hour: If not Obamacare, then what? People who don’t like the Affordable Care Act voted overwhelmingly for Trump. Republican policymakers, including President-elect Donald Trump, have vowed to repeal it. But a clear replacement plan that would beat Obamacare’s costs, coverage levels, and attempts at socio-economic fairness has yet to materialize. So, everyday Americans dissatisfied with the current insurance system are left puzzling through the actuarial tangle: What’s fair, and what’s not? And how to make it work better than it does now?

I recently interviewed a dozen people in three small towns near Harrisburg, Pennsylvania—a region that went for Trump by wide margins—and found several broad reasons for dissatisfaction with the Affordable Care Act. Americans have grown too lazy and entitled, some feel, and the Trump administration’s health-care proposals should promote greater personal responsibility. Others are simply confused by the law, what exactly it changed, and where they fit within the new health-care regime. But others liked the idea of universal health insurance and thought the law would help them. When it didn’t, some turned to Trump to tear it all down and start again.

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Kelly Kaiser, the owner of the Grace Kelly salon, has seen her health insurance premiums rise every year since Obamacare was implemented. Unlike people with employer-provided health care, small-business owners and independent contractors must buy insurance on their own through brokers or the Obamacare exchanges. That’s especially true for someone like Kaiser, who is single, so she’s not covered by a spouse’s plan. Things got even worse for her this year, when several insurers pulled out of Pennsylvania’s Obamacare exchange, leaving her with just a few options, she said. Now, she pays $655 a month, and her deductible is $10,000. “Welcome to my shoes,” she said.

Kaiser has hit one of Obamacare’s snags: For many people, it’s still very expensive, especially if, as Kaiser does, they make a bit too much money to qualify for the subsidies. And even if they’re benefitting from the slew of other things the law changed, they either don’t notice it, or the cost of their plan doesn’t seem worth it.

Kaiser likes Obamacare’s under-26 provision and its ban on discriminating against people based on pre-existing conditions. She’s even fine with the mandate to buy insurance. Still, she wants Obamacare repealed.

I told her that some experts think doing that might make things even worse—that repealing Obamacare might cause insurance markets to collapse, giving people even fewer options, if any. But, she said, “there’s nothing now!” How could it get any worse?

She trusts Trump to dream up something better. “He’s a business person, that’s why we all voted for him,” Kaiser said. “He's been successful all on his own. We need to run this country like a business.”

The financial pinch she’s feeling is compounded by her sense that other people are getting health care for free. “If I close my doors, being single, I could make more money than working here, with all the stuff they’ll give me” she said. “They have their health care, their food stamps, their iPhones ... They got it made!”

She, too, said she doesn’t mind if high earners are made to spend more on health care— “but everybody's gotta get out there and get a job to help pay for it.”

Her client, the mom getting her hair cut, nodded along, adding that she thinks there’s not enough incentive to work in society.

I heard this gripe from several people. Their health-care costs are skyrocketing, and meanwhile, there are people on Medicaid, which has its own issues, but looks like the lap of luxury when you have a five-digit deductible.

I drove up the road, past stands selling farm eggs and a “Believe in Jesus” sign, to York, an old manufacturing town that represents the Trump phenomenon in miniature. It’s the onetime home to York Peppermint Patties. The factory that made York Peppermint Patties moved up the road to Reading, then relocated to Mexico in 2009, taking 300 jobs with it. Now, one bar’s door announced the place was “condemned,” and a yellow sign posted on the outside of a bookstore read, “we ship to prisons.” Sixty-three percent of people in the county voted for Trump, compared to 49 percent in the state overall.

Near the bookstore, I met Willie Standley, the owner of the New Hub Shop, which sells men’s clothes and performs alterations. Standley’s the owner, and he’s also the rare African-American Trump voter. He doesn’t like the Affordable Care Act either; he thinks it costs too much for something a healthy man like him barely uses. (He’s a teetotalling vegan.) He is also worried about what he considers to be a culture of entitlement. In this, Standley’s not an outlier: In October, 66 percent of Trump supporters said the economy is rigged for people who receive government assistance.

“I’m worried about people being willing to work hard and stopping being dependent on the government,” he said. “The complacency I see in people is ... sad at times.” He thinks whatever comes after Obamacare should be voluntary. And, of course, he thinks it should be cheaper.

The people who didn’t outright dislike the health-care law were perplexed by it. Ken Brown, a 38-year-old small-business owner, had signed up for health insurance through the exchange, but he wasn’t sure what Obamacare was. Is it the website, Healthcare.gov? Is it the plan that he signed up for? This is where Obamacare’s crafters left themselves wide open to doubt. The answer is that Obamacare is indeed a government website ... but also private insurance! (Which the government makes you buy).

Patricia Toth McCormick / Getty

In the evening, I drove to Carlisle, a cute exurb in the Cumberland Valley. The main thoroughfare had bustling bars and light-wrapped trees—and a storefront with a “Closing: Everything Must Go” sign. Tami Shaffer, the owner of a soap store called No Common Scents, hopes that won’t be her fate. She and her husband put everything they had into the place, which looks like the kind of small-town shop that Anthropologie was modeled on, with white Christmas trees and soft lighting. They run it themselves, spending long hours making their sweet-smelling products. When they book gigs for their other job, as videographers, they ask family members to come mind the store. When Shaffer called a broker earlier this year to ask about health insurance, she remembers being told it would cost $500, and that she doesn’t qualify for subsidies. Later, she was told she qualified for Medicaid. When she called back a few days before this year’s open-enrollment deadline to ask about 2017, they told her they weren’t sure yet whether she was Medicaid-eligible. “They didn’t seem to know what they were talking about,” Shaffer said.

Shaffer believes she’s not on Obamacare—understandably so, since she didn’t go through Healthcare.gov to buy her plan. But Medicaid expansion was yet another little-heralded element of the Affordable Care Act. Shaffer, an independent, didn’t vote for Trump, but she still wants Obamacare “radically changed or eliminated.”

“It would be nice to have this health-care thing off of me,” she said. “For small businesses, I wish they would revisit how we’re dealt with.”

* * *

Few people I met pined for old days of the untamed individual insurance market, in which people could be denied coverage for acne or thrown off their plans when they needed them most. Lynn Keltz, a health-care navigator in Harrisburg, said Obamacare enrollees in the area were most concerned about rising deductibles—as are marketplace enrollees around the country.

Deductibles are rising because not enough young, healthy people signed up for Obamacare, mandate be damned. But the plans that Republican leaders have proposed so far wouldn’t necessarily address high deductibles, according to Sara Rosenbaum, a professor of health policy at George Washington University. Both Rep. Tom Price, Trump’s nominee to lead the Department of Health and Human Services, and House Speaker Paul Ryan have proposed expanding the use of health savings accounts—essentially a subsidy, not tied to income, that can be used to pay the deductibles on health plans. (Price’s proposal, in fact, would simply change the name ‘‘high-deductible health plan’’ to “HSA [health saving account] qualified health plan.”)

But right now, even people with the income-based subsidies of Obamacare are struggling to pay their deductibles. Back in Gettysburg, I talked to Debra Starry, a woman who manages an art gallery that sells idyllic landscape paintings. At first, she thought Obamacare was meant for people like her. She’s single, she works full-time, and she struggled to afford insurance before the Affordable Care Act was passed. At 59, getting covered isn’t cheap.

The first year she signed up, her premium was $267. The second year, it went up to nearly $292. “I crunched my budget and made it work,” she said. This year, the premium was the same, but her deductible rose from $1,700 to $4,500, she said. Every year, her plan has been cancelled, and this year, there were only four options to choose from.

Unlike some of the others I met, Starry has relied on her insurance. In the middle of the summer, she woke up bleeding and with terrible stomach cramps, and she ended up needing a colonoscopy. She’s had swollen lymph nodes biopsied and a mammogram that cost $300. (Some, but not all, mammograms are covered without a deductible on Obamacare.) She’s still paying two hospitals back in installments for $2,300 in medical bills.

“When Obamacare came along, I thought, it's going to be signed in, I'm going to take advantage of it,” she said, tearing up. “And I’m no further ahead going into the fourth year than I was at the beginning. I haven't gotten what I hoped for.”

She doesn’t want health insurance to go back to how it was a decade ago. “If they just let it go out the window, without something to structurally hold it up until they figure it out, I won’t be able to afford insurance again. I'll be back to square one,” she said. “I think there's a way they can fix it and make it work better.”

She suggested, at one point, that maybe there could be a separate insurance plan that’s managed by the government for people like her. It’s an idea similar to the public option that Hillary Clinton had at one point proposed. But Starry didn’t trust Clinton enough to vote for her. “She scares me,” she said.

Health care, for all its tediousness, is extremely emotional. Sickness brings out our most vulnerable selves. When the system built to keep you alive lets you down, the urge to start afresh can be irresistible.

“I hope that Mr. Trump is working with someone as we speak on this,” Starry said. “Figure it out, guys. That’s what we hired you to do.”