On January 20—quibbling over the Electoral College notwithstanding—Donald Trump will become president. For the first time in the seven years since its passage, Republicans will have what they need to repeal the Affordable Care Act.
Trump has made some remarks indicating a full repeal of Obamacare might not be in the cards. But his own repeated campaign promises, the Republican Party platform, and dozens of congressional votes make it fair to expect that most of the law will be repealed or rolled back over the coming months. The three biggest provisions of the ACA—Medicaid expansion to all low-income people, the individual mandate to buy insurance, and the creation of a subsidy-backed private-insurance marketplace—are the most obvious candidates for the axe. Unfortunately for many of the millions of voters who elected a Republican president and Congress, cutting those provisions could place their lives in disarray.
The full-throated Republican rebellion against Obamacare since its passage was both a rejection of Obama’s policies and a reaction to a dysfunctional health-care system that proved unaffordable to many. Trump has been widely credited for tapping the economic anxiety of many white working-class voters, promising to help them make ends meet and make their lives better.
But white people who make less than $50,000 annually have derived particular benefit from Obamacare’s provisions, especially in the Rust Belt and in rural, white Republican strongholds. It’s been widely reported that rates of uninsurance dropped more for people of color than for white people in the years since Obamacare was passed, but that’s largely because people of color are generally more likely to fall into lower income brackets, where the Medicaid expansion and tax subsidies had the greatest effect on increasing coverage.
When stratified by income, however, it appears that among those whose incomes are less than 200 percent of the federal poverty level—just around $49,000 for a family of four this year—whites actually gained insurance at relatively high rates. Data from the 2016 and 2014 Current Population Survey Annual Social and Economic Supplement shows that the proportion of uninsured low-income white people dropped by 8.6 percentage points from 2013 to 2015, a reduction that was roughly similar to the decrease among Hispanic people, but which outpaced the national average of 8.1 percentage points, and dwarfed the decrease among black people in the same income groups. Members of the white working class, in other words, were particularly likely to gain coverage from Obamacare.
A closer look at some of the states that Trump captured reveals a much more nuanced picture of Obamacare’s role in the lives of low-income white people than his campaign-trail rhetoric might suggest. In the “coal-miner country” of Appalachia, the Affordable Care Act has been vital in shoring up collapsing rural-health systems that have become overburdened with the mounting health problems of their constituents.
West Virginia, which has been wracked by public-health problems, pollution, and has the most per-capita drug deaths in the country, has had to embrace Obamacare’s Medicaid expansion and subsidies in order to provide affordable healthcare for all those coal miners, other low-income workers, and their extraordinary rates of disease and disability. While premiums for exchange plans have increased by double digits across the state, that largely reflects the cost of covering such a sick pool of rural enrollees, and most people in the state will never see those increases because of subsidies.
Just across the Big Sandy River, Kentucky’s corner of Appalachia is dealing with the same issues for similar populations of rural, low-income white people with similar health problems. Kentucky also expanded Medicaid to all low-income people, and over 60 percent of all the state’s residents approve of that expansion. Even more support maintaining the expansion in the future. Notably, the support for all of the Obamacare provisions in the state is lower when referred to by that name then when referred to by Kentucky’s own branded name for its exchange program—Kynect.
In the vaunted blue-collar pieces of the Rustbelt, where Trump broke through Hillary Clinton’s “blue wall” in his near-sweep of Midwestern battlegrounds, Obamacare also holds sway in the lives of lower-income working white people. In Ohio—whose Republican Governor John Kasich accepted the Affordable Care Act’s Medicaid expansion—the law helped cut uninsurance to 6 percent. The lead crisis in Flint, Michigan, prompted an emergency expansion of Medicaid to care for mothers and children affected by lead poisoning. And although Flint is a majority-black city, its lead crisis is a harbinger for other lead-related infrastructure crises in Rustbelt towns, which mostly skew rural and white. For citizens in those towns—quite literally in Middle America—maintaining robust federal public insurance could be a matter of life and death, and of the future of their children.
But insurance coverage is only a means to an end, and that end is health. While it is undeniable that several million Americans face rising or unaffordable premiums and prescription drugs, it is also true that millions of the worst-off Americans gained coverage at low cost or at no cost, and that it allowed many of them to visit physicians or go for check-ups without fear of bankruptcy for the first time in their lives. Most of those first-timers are white people working low-paying jobs, and for them that security couldn’t have come at a better time. Especially in the rural, whitest pockets of America, the opioid crisis and a staggering number of other morbidities have actually reversed the declining trend in mortality rates among white Americans that has often been taken as a birthright. For much of this group of people, their generation is the first to give birth to children who will not live longer than them.
For all the angst about Obamacare’s overreach, rural white America has long been dependent on public insurance. For one, these residents tend to be older than urban counterparts and thus rely more on Medicare. But even among the non-elderly, a quarter of all rural residents rely on Medicaid or other public insurance for their basic health-care needs. Many of these residents rallied around Trump’s vague plans to ease their economic issues, including the erosion of stable union-protected jobs. But one of the benefits that these people have lost the most and that has contributed to family economic woes the most is employer-sponsored health care. Public insurance—now bolstered by Obamacare—has taken up much of the slack.
Extending health-insurance coverage is not, of course, a guarantee of affordable or useful healthcare. But the ACA actually does fund several direct public-health initiatives that attempt to address rural America’s deepening health issues. The president-elect has largely neglected these in his scathing analysis, but the law authorizes funding for hundreds of new community-health centers and for sending physicians to long-neglected communities outside of urban centers. While so far, the law’s implementation has been a severe strain on rural hospitals, clinics, and the healthcare workforce that caters to many low-income white patients, that strain has come because millions of people with lifetimes of unmet medical need now have a way to finally get into the system. If the goal is to help these people, that might be a case for expanding the ACA’s coverage and capacity-building measures, not abandoning the attempt.
All but one of the plans currently in consideration by the congressional Republican leadership, however, would not only diminish Obamacare’s subsidies, but also restrict Medicaid in historically novel ways. The sudden removal of billions of dollars of Medicaid and subsidized private payments to rural health centers, reducing support below even 2012 levels, could be the final blow for many places that are the last lines of defense for America’s whitest communities.
Although tax reductions and lower premiums would likely benefit many of the healthiest and youngest adult residents of white America, they would distinctly harm exactly the kinds of vulnerable people that Republicans have placed at the center of their narrative.
According to an analysis from The Economist, the health of a county was the strongest predictor aside from race and education of the likelihood of its voters to switch from voting for President Obama in 2012 to voting for Trump in 2016. There might not be causality there, since on a county level, poor health outcomes are strongly associated with rurality, which is itself associated with whiteness, low-incomes, and less education. But the places that suffer the most and have flipped for Trump by the highest margins stand out as Rustbelt counties that have been hit hard by a number of other issues. While Obamacare has not been enough to solve their problems, the plans so far advanced by Republicans restrict federal funding for health crises and public health, as opposed to extending new avenues of coverage, care, and access.
The people who desperately need better health-insurance coverage and a more robust healthcare infrastructure among the stereotypical Republican base are black-lunged ex-coal miners in West Virginia who’ve lost pensions and union protections; children with opioid-addicted parents; hard-scrabble farmers who work 100-hour weeks just to rise above the poverty level; and abandoned auto- and steel-industry employees in polluted towns who now need public benefits just to feed their families. If anything, the years of experimentation with Obamacare have indicated that more investment is necessary to protect them. But it appears America will be going the other way.