The Washington PostDemocracy Dies in Darkness

Opinion Obamacare is probably toast. And a lot of poor, white Trump voters will get hurt by it.

Donald Trump. (SAUL LOEB/Agence France-Presse via Getty Images)


Donald Trump has chosen GOP Rep. Tom Price of Georgia, a longtime critic of the Affordable Care Act, as his secretary for Health and Human Services. This likely means that, at best, the health law will be repealed and replaced by something that covers far fewer people, or that, at worst, it will get repealed outright, leaving even more people without coverage.

So what does this mean for poor and working-class white Trump voters who are currently benefiting from the law, some no doubt enjoying health coverage for the first time in their lives?

Jonathan Cohn has a good piece explaining what the choice of Rep. Price means in policy terms. Unlike many Republicans, Price has at least given a lot of thought to how to replace the ACA. But Price’s own replacement proposal would roll back the Medicaid expansion, a substantial portion of financial assistance for others getting coverage, and a fair amount of regulation of the individual market. And so, the likely end result (again, at best) is that a lot of the 20 million people who would lose coverage due to repeal will remain without coverage, and protections for those with bad medical conditions will be eroded.

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The core philosophical difference here is that conservatives want far less in government spending and regulations designed to cover poor and sick people, protect consumers and enforce a minimum standard for coverage. As a result, they are willing to tolerate far lower standards in those areas, though some also want conservative reforms to strive to make very cheap bare-bones catastrophic coverage widely available. Liberals think we should spend and regulate to the degree necessary to move toward universal care and see expanded and improved coverage as part of a broader effort to progress toward a higher societally guaranteed minimum standard of living. Conservatives won the election, and apparently, we are now going to do it their way. Elections have consequences.

At a rally in Valley Forge, Pa., Nov. 1, Republican presidential candidate Donald Trump outlines how he would "repeal and replace" the Affordable Care Act. (Video: The Washington Post)

Indeed, all this should immediately cast doubt on the notion that Trump will clash with congressional Republicans over the future of the safety net. During the primaries, Trump famously said he would not allow people to “die on the street,” which, along with his vows not to touch entitlements, led many to see him as an unorthodox Republican when it comes to the proper scope of government protections for the poor and unhealthy. But now Trump appears prepared to go along with the most conservative congressional Republicans on these matters.

I have obtained new numbers from the Gallup-Healthways Well-Being Index that suggest that a lot of poor and working-class whites — who voted for Trump in disproportionate numbers — have benefited from Obamacare, meaning they likely stand to lose out from its repeal (and even its replacement with something that covers far fewer people). Gallup-Healthways numbers from earlier this fall showed that overall, the national uninsured rate has plummeted to a new low of 10 percent, a drop of over six percentage points since the law went into effect — which alone is a major achievement.

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But that drop, it turns out, is even more pronounced among poor whites. Gallup-Healthways tells me that among whites without a college degree who have household incomes of under $36,000, the uninsured rate has dropped from 25 percent in 2013 to 15 percent now — a drop of 10 percentage points. It’s often noted that the law has disproportionately expanded coverage among African Americans and Latinos. That is correct, but it has also disproportionately expanded coverage among poor white people.

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Now, it’s hard to know how many people we’re talking about here. But other evidence supports the idea that a lot of red state voters have gained coverage from the law. In some parts of rural Kentucky, the Medicaid expansion has greatly expanded coverage. And CBS News recently reported that even some Republican officials in the GOP-led states that expanded Medicaid are not prepared to see that evaporate. Gallup-Healthways numbers also show that the drop in the uninsured rate has outpaced the national average in some red states that have expanded Medicaid, like Kentucky, Arkansas, and West Virginia.

Did people benefiting from Obamacare who voted for Trump really expect repeal to happen? I think we need more reporting on this question. Yes, Trump did repeatedly say he would repeal Obamacare. But he also said he would replace it with “something terrific.” And he explicitly went out of his way to create the impression that he does not agree ideologically with Republicans who are hostile to government efforts to supply health care to those who can’t afford it.

Now, it’s always possible that many voters backed Trump in the full knowledge that their Obamacare might be repealed, for other reasons — because, for instance, he’ll supposedly bring manufacturing and coal jobs roaring back. Before long, those voters will learn whether their bet was a well-placed one. It’s also possible that Trump will surprise us all and insist on some kind of replacement that somehow preserves much of Obamacare’s coverage expansion. And a kick-the-can-down-the-road scenario which keeps deferring the harshest fallout from repeal is also a possibility.

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But it now looks more likely that we’ll see a substantial rollback of the progress toward universal health coverage we’ve seen in the past few years. News organizations love to venture into Trump’s America to hear voters explain that Trump spoke far more directly to their economic struggles than Democrats did. Maybe now we’ll get more coverage of those inhabitants of Trump’s America who are set to lose their health care, too.


* TRUMP LEANING TOWARD ROMNEY: The Post reports that despite the lobbying against it by some top advisers, Trump is leaning toward Mitt Romney as secretary of state:

Trump is looking for assurances that Romney … who has championed a muscular and at times interventionist foreign policy, could be trusted to defend and promote Trump’s markedly different worldview in capitals around the globe. … Giuliani has openly campaigned for the job and has told friends that he is likely to get it. But Trump’s team has determined that it may be challenging and even unlikely for Giuliani to win Senate confirmation.

Giuliani — impulsive, snarlingly vindictive and thoroughly incapable of allowing differing views to pierce his unshakable righteousness and certainty — could not be more ill-suited to this position. So hope for Romney.

* TRUMP IS UNLIKELY TO RESUME TORTURE: The New York Times reports that experts believe the obstacles to resuming waterboarding are probably too difficult to overcome:

Federal law, international pressure and resistance from inside the C.I.A. stand in his way. Dozens of prisoners developed persistent psychological problems after enduring torture … In authorizing waterboarding … government lawyers reasoned that there would be no lasting damage to prisoners, a key factor in concluding the tactics did not qualify as torture. That argument would be difficult to make now.

Of course, this presumes that Trump cares about those things known as “facts,” “laws” and “arguments.”

* TRUMP’S CHOICE OF SESSIONS SCARES IMMIGRATION ADVOCATES: Politico reports that immigration advocates are deeply worried about Senator Jeff Sessions becoming Attorney General, because he’ll be well positioned to implement his hard-line views:

[Sessions would have] wide latitude over the kinds of immigration violations to prosecute and who would be deported. … Sessions would be able to direct limited department resources to pursuing immigration cases … He would be in charge of drafting legal rationales for immigration policies under the Trump administration. And Sessions … could find ways to choke off funding for “sanctuary cities.”

This is another area in which Democratic senators must press hard during his confirmation hearings to nail down — and showcase to the nation — his actual views.

* NO, TRUMP DIDN’T WIN A LANDSLIDE: Trump has been claiming he won the electoral college in a “landslide.” The Los Angeles Times delivers the bad news:

A study of electoral vote results by John J. Pitney, an author and professor of government at Claremont McKenna College, shows that Trump resides on the lower end of the electoral vote scale. He won 56.97% of the electoral votes up for grabs by virtue of his state wins. That places him 46th out of the 58 elections since George Washington’s era, Pitney found.

Meanwhile, Hillary Clinton’s popular vote lead now stands at 2.3 million, or 1.7 percentage points.

* TRUMP SPOX DEFENDS ‘FRAUD’ CLAIMS, FLOPS MISERABLY: Nate Cohn reports that a spokesman for Trump gamely tried to defend Trump’s latest claims that vote fraud was responsible for him losing the popular vote:

Jason Miller, his communications director, cited two studies that he said offered examples of voter fraud: a 2014 Washington Post study on noncitizen voting and a 2012 Pew study on the poor state of voter registration files. Neither study could plausibly be construed to indicate that millions of illegal voters cast ballots in this election. Both were conducted well in advance of the election, and neither supports anything like what Mr. Trump has suggested.

As I’ve argued, the latest voter fraud claims may signal a major wave of voter suppression. Previous efforts have been based on nonsensical justifications, so why would this be different?

* THE TRUMP TWEET OF THE DAY, SHRED-THE-CONSTITUTION EDITION: Another day, another horrible tweet:

The Supreme Court has ruled that burning the American flag is protected speech, but the fact that Trump is casually floating the idea of revoking citizenship is pretty big news, too.