Why Did People on Medicaid Vote for Trump?

A new report explores why those who benefitted from Obamacare’s Medicaid expansion supported the man who promised to reverse it.

David Goldman / AP

Here’s a question that’s baffled health reporters in the months since the election: Why would people who benefit from Obamacare in general—and its Medicaid expansion specifically—vote for a man who vowed to destroy it?

Some anecdotal reports have suggested that people simply didn’t understand that the benefits they received were a result of the Affordable Care Act. That was the case for one Indiana family The New York Times described in December:

Medicaid has paid for virtually all of his cancer care, including a one-week hospitalization after the diagnosis, months of chemotherapy, and frequent scans and blood tests.

But Mr. Kloski and his mother, Renee Epperson, are still not fans of the health law over all. They believed that it required that Mr. Kloski be dropped, when he turned 26, from the health plan his mother has through her job at Target — not understanding that it was the law that kept him on the plan until he was 26.

Others, like this woman Vox’s Sarah Kliff met in Kentucky, were happy with Obamacare but didn’t believe Republicans would actually dismantle it:

We spoke a good deal longer about the Affordable Care Act, and the possibility of repeal. Mills said she had gone into the voting booth confident that Republicans wouldn’t dismantle the law, despite their promises. How could they, when people like her had become so reliant on it?

I, meanwhile, have encountered people who were on the Obamacare exchanges and, though they were glad to be able to afford health insurance for the first time in years, still wanted the law repealed because they felt Obamacare coverage was too expensive. Here’s one shop owner I interviewed in Pennsylvania:

“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.”

A report out this week from the Kaiser Family Foundation puts some data behind these anecdotes. The answer is, it seems, all of the above: Many exchange enrollees thought their plans were too expensive, and many beneficiaries of the Affordable Care Act’s Medicaid expansion didn’t realize their free health insurance was the result of Obamacare. And Marketplace enrollees told KFF they trusted Trump to “craft a plan that would work better for them.”

The issue brief, written by KFF researchers Jennifer Tolbert and Larisa Antonisse, relies on focus groups KFF conducted in December in Michigan, Ohio, and Pennsylvania with a total of 48 Trump voters. Twenty-three were on Medicaid, 21 were covered through the Obamacare exchanges, and four were uninsured.

The brief quotes the 21 Marketplace enrollees as saying the plans are too complex, and most felt their only option was a high-deductible plan because premiums were too expensive.

“I have to go based on what I can afford, which is awful. 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. I have insurance and I don’t use it,” said Deborah, a woman on the Obamacare exchange in Columbus, Ohio.

Still, the authors write, many worried about the implications of repealing Obamacare, so they wanted the law replaced simultaneously. Preferably, with something that makes their health care more affordable. (One potential obstacle to that dream: “Universally, participants opposed the requirement to have health insurance or pay a fine, calling it ‘un-American,’ even those who were otherwise happy with their coverage.”)

But the participants also had bad news for the Republicans, many of whom are proposing Obamacare replacement plans that rely on high-deductible plans paired with health savings accounts: The focus-group participants hated high deductibles, didn’t know what HSAs are, or did not have the necessary savings to put in them.

The quotes from Medicaid enrollees were grimmer—and perhaps more frustrating for health wonks. All three states where the focus groups took place adopted the Obamacare Medicaid expansion, even though they went for Trump in the 2016 election. The Medicaid enrollees in the KFF panel were happy with their coverage, and some said they could see doctors and fill prescriptions for the first time in years.

Here comes the depressing part (emphasis mine):

Although almost all of the participants in the Medicaid focus groups became newly eligible for Medicaid coverage in 2014 due to their state’s expansion of the program under the ACA, most Medicaid participants did not realize that their coverage was related to the ACA.

They wanted to keep their coverage, the report authors write, and “voiced distress about the implications of repeal.”

“[Trump] said 100 times ‘Repeal and replace Obamacare,’ but the repeal part did worry me. Only in that the reason that I have healthcare is because of something that was in Obamacare,” said Kyle, a Harrisburg man who is on Medicaid.

What to take away from this, as Republicans continue to promote replacement plans that would do things these Trump voters say they don’t want?

Here are three possible interpretations:

  • Medicaid recipients only opposed Obamacare because they didn’t fully understand how it worked. In this case, policymakers might face serious blowback if they try to scrap the law. (And Democrats seem to have failed in not hammering home the fact that Medicaid expansion was part of Obamacare).
  • Obamacare was not as big of a factor in support for Trump and Republicans as initially seemed. The KFF report states several times that “health care was not a major factor in their votes for president.” That could mean Republicans should not interpret their electoral victory as a referendum on Obamacare.
  • People were broadly unhappy with America’s health-care system, and Obamacare, being the most recent and biggest change, took the blame.

That last one might be the most likely—and also the hardest to fix.