The Washington PostDemocracy Dies in Darkness

Public pans Republicans’ latest approach to replacing Affordable Care Act

Health-care experts say the Affordable Care Act is stable, but President Trump and congressional Republicans could push it over the cliff into a "death spiral." (Video: Daron Taylor/The Washington Post)

In strategy and substance, the American public disagrees with the course that President Trump and congressional Republicans are pursuing to replace the Affordable Care Act with conservative policies, according to a new Washington Post-ABC News poll.

Large majorities oppose the ideas at the heart of the most recent GOP negotiations to forge a plan that could pass in the House. These would allow states to choose whether to keep the ACA’s insurance protection for people with preexisting medical problems and its guarantee of specific health benefits.

Public sentiment is particularly lopsided in favor of an aspect of the current health-care law that blocks insurers from charging more or denying coverage to customers with medical conditions. About 8 in 10 Democrats, 7 in 10 independents and even a slight majority of Republicans say that should continue to be a national mandate, rather than an option for states to retain or drop.

Read: Full Post-ABC poll results

“All states should be required to do the same thing,” said Bayonni Handy-Barker of Killeen, Tex., who supports nationwide requirements on both preexisting conditions and minimum benefits for insurance plans. As the 25-year-old Army veteran and political independent reasoned, “when you have people picking and choosing what to cover, you have this system of holes and disruption and disorder.”

Those views heighten the challenge for Trump and congressional Republicans as they try to thread their way through disagreements over health-care policy within the House GOP conference. The Freedom Caucus, the chamber’s most conservative faction, announced its support on Wednesday for an amendment that would permit individual states to decide whether insurers must treat all customers the same. A state could ask for federal permission to let insurers again charge higher prices to people with preexisting conditions, as long as it offered high-risk insurance pools for such customers.

The amendment also would let states seek federal approval to drop the “essential health benefits” the ACA requires in all health plans sold to individuals and small businesses.

These latest ideas are an effort to recover after a remarkable failure last month in attempting to pass a health-care bill. House Speaker Paul D. Ryan (R-Wis.), who has championed the ACA’s repeal for years, canceled a vote on the American Health Care Act shortly before the roll call was to begin because the chamber’s ­Republican majority was so splintered. Since then, the White House has been prodding GOP lawmakers to regroup, unite and vote quickly on a new version of the legislation.

Affordable Care Act remains ‘law of the land,’ but Trump vows to explode it

The Post-ABC poll shows that, beyond the criticism of GOP proposals for devolving health policy to the states, many Americans appear leery in general about a major overhaul to the health-care law often called Obamacare, with 61 percent preferring to “keep and try to improve” it, compared with 37 percent who say they want to “repeal and replace” it. About three-quarters of Republicans prefer repealing and replacing the ACA, but more than 6 in 10 independents and nearly 9 in 10 Democrats favor working within its framework.

In addition, the president’s strategy of trying to develop a plan with conservative Republicans contrasts with the public’s desire for a bipartisan approach. A 43 percent plurality of Americans say he should work with Democrats to change the law, while 26 percent would rather Trump work with the conservative Republicans. Another 24 percent volunteer that he should work with both groups.

Both sentiments echo criticisms of the ACA's 2010 passage on a party-line vote. A Post poll the month the law was enacted found 47 percent of Americans saying that President Barack Obama and congressional Democrats did not make a ­good-faith effort to cooperate with ­Republicans. In his first months in office, Trump has said he was open to a bipartisan approach but has put the onus on Democrats to offer concessions and predicted that Democrats would have to come to him "after Obamacare explodes."

On Sunday, the president returned to that theme with a new tweet: “ObamaCare is in serious trouble. The Dems need big money to keep it going — otherwise it dies far sooner than anyone would have thought.”

The new survey suggests significant political risk to Trump in trying to undermine the law, with a mere 13 percent saying he should try to make it fail as soon as possible. By contrast, nearly 8 in 10 (79 percent) say he should try to make the ACA work as well as possible, including about 6 in 10 Republicans and 8 in 10 independents.

Views of the law have been sharply divided along partisan lines since its passage. For several years, polls showed more opposition than support, but the law’s popularity rose sharply after Trump’s election. Polls this winter found widespread opposition to the GOP alternative.

The Post-ABC poll is the first that has measured public attitudes toward the possibility of giving states control over insurance rules covering preexisting medical conditions and many plans’ mandated benefits.

In trying to undo the ACA’s “essential benefits” requirement, the Freedom Caucus reasons that insurance premiums could be lower if people could buy less comprehensive plans and that each state should decide what benefits, if any, must be covered.

Some people agree. A 51-year-old Republican businessman in Connecticut, who recently sold a group of restaurants, said that his dishwashers and servers were able to buy relatively skimpy, inexpensive “catastrophic” health plans before the ACA. But once the law required more comprehensive coverage, “what happened was, nobody took it,” he said, speaking on the condition of anonymity to protect his former employees’ privacy. Still, the businessman said the federal government should set nationwide requirements to avoid chaos with different insurance rules for companies that operate in more than one state.

White House turns up heat on Congress to revise the Affordable Care Act

The survey finds 62 percent of Americans also support keeping federal requirements that many plans cover preventive services, maternity and pediatric care, hospitalization and prescription drugs, while 33 percent say states should decide what, if any, ­minimum coverage should be provided. Just under half of ­Republicans (46 percent) favor federal requirements, with support at 67 percent among independents and 80 percent among Democrats.

Sandra Gibbins, a former insurance company manager from Clarksburg, W.Va., who is now on Medicare, is generally upbeat about the president’s efforts to revise the health-care law. But as a two-time cancer survivor, the independent worries what coverage would be available for people like her. If she weren’t on Medicare, she wondered, “where would I go for insurance?”

During the past seven years, states have diverged in their approach to a central aspect of the ACA, with most Democratic-led states accepting federal funding to expand Medicaid and most Republican-led states resisting. Despite that sharp difference, majorities in both groups of states want to preserve two core ACA insurance rules, the poll shows.

The Post-ABC poll was conducted April 17 to 20 among a random national sample of 1,004 adults interviewed on cellular and landline phones. Overall results have a margin of sampling error of plus or minus 3.5 percentage points. Questions about ­national or state control of health rules were asked of a random half-sample of respondents and have an error margin of five percentage points.

Emily Guskin contributed to this report.