A 30-year-old cancer survivor in a small West Virginia town worries how she would pay for treatment if a tumor returned. A Chicago doctor wonders whether her hospital would cut back on care for ill or premature infants. In Northern Virginia, the head of a small nonprofit clinic lies awake at night fearing a surge of uninsured patients she couldn’t afford to take in.
Two weeks after the unexpected election of Donald Trump, the incoming administration and the Republicans who control Congress have defined few specifics for how they will carry out their promise to eliminate the Affordable Care Act. Yet the shift in Washington’s political geometry already is stoking anxiety among many of the 11 million people who have gained private insurance under the law, as well as among those who help care for them.
At the same time, some Trump voters with ACA health plans relish the idea of shedding the law. “How could it be worse?” asked Carl Galloni, who sells and installs garage doors in North Carolina. “My man won, so I’m not frightened [of] what he’s going to do.”
Such clashing perspectives offer a ground-level view of the two Americas exposed by a singularly polarizing presidential campaign — a campaign driven by profound disagreements over basic values, including the role of government.
On few matters is the political divide as pure as it is on health care. Early this fall, nearly 9 in 10 Democrats said in a survey for Harvard University and Politico that they thought the government has a major role in improving the health system, and 80 percent said the ACA is working well. Among Republicans, only about a quarter said the government has a major role, while an equal share said the government has none. Nearly 90 percent said the ACA is working poorly.
These beliefs “correlate perfectly with the [Hillary] Clinton versus Trump vote,” said Robert J. Blendon, a Harvard professor who specializes in public opinion on health issues.
In Fairmont, W.Va., Mina Schultz voted for Clinton. As she works at a community health center there, helping patients sign up for ACA coverage and her state’s expanded version of Medicaid, she sees firsthand how political health care has become. Some of her clients are now asking if it all is going to go away.
For Schultz, the fate of the law also is intensely personal. In 2011, when she was 25, she assumed she’d go uninsured for several months between graduate school and joining the Peace Corps. But her parents had heard that the fledgling ACA let them include her on their insurance policy through age 26, and they did.
That May, three weeks after getting her master’s degree in French, a recent pain in her right knee was diagnosed as bone cancer. So she happened to be insured when, instead of going overseas, she spent the next year in and out of the hospital for nine rounds of chemotherapy and a total knee replacement.
She moved back home to Fairmont when she was 27, first taking a crummy job that came with insurance, and then, because she’d become intrigued by the health-care system, finding the enrollment-counseling position at the Monongahela Valley Association of health centers. Her job, created through a federal grant, does not provide health benefits. Schultz signed herself up for an ACA Blue Cross-Blue Shield plan.
These days, in addition to work, she is pursuing a second master’s degree — in health policy. She still needs follow-up tests and medicine, including for the chronic kidney disease that is a remnant of her treatment. She also deals with anxiety and, since the election, a new fear: the future of her insurance and that of the people she has helped to choose health plans.
The president-elect, she knows, has been saying that the government should continue to forbid insurers to refuse people with preexisting medical problems — problems like her bone cancer. She also knows that, if the ACA ends, insurers may be able to revert to setting annual or lifetime limits on customers’ coverage.
“There’s not a day that goes by that I don’t think, ‘What if my cancer comes back?’ ” Schultz said. The prospect of capped insurance during a second bout of such expensive treatment “is terrifying. . . . I’m somewhat panicked.”
But in Jamestown, N.C., a suburb of 3,000 between Greensboro and High Point, Galloni, 61, is hopeful. He has never changed his party affiliation since registering as a Democrat at 18, but he often crosses party lines and this month was enthusiastic in his vote for Trump.
A small-business man, whose company consists of his wife and four employees, he is fed up with the ACA marketplace — the bureaucracy, the diminishing choice and the spiking price. Until now, Galloni has gotten federal subsidies because he wasn’t taking a salary from his company for several years. But he’s decided to draw some income again, so the subsidies are going away. The monthly premiums to cover him and his wife will leap from about $400 this year to $2,000 in January if he keeps his Blue Cross plan. He isn’t sure yet whether he will.
What gives him hope is the talk he’s heard from Trump about letting insurers sell health plans across state lines. “Why can’t I go three miles into Virginia and get my health insurance there if it’s cheaper?” he said. “Competition just makes the world go around.”
Among health-care professionals, the possibility that the ACA could soon be dismantled is setting off jitters, especially in places where many patients are poor.
At the University of Chicago’s children’s hospital, three-fourths of the babies in the neonatal intensive care unit have mothers on Medicaid. Illinois is one of 31 states that expanded Medicaid under the law. Bree Andrews, a pediatrician and neonatologist there who runs a center for healthy families, worries that a loss of extra Medicaid money the ACA has funneled into the hospital might mean fewer social workers or lactation specialists.
“I think it’s going to throw us into free fall,” Andrews said. “Neonatal care is expensive, and there is a lot of it. If hospitals don’t know how they will get paid . . . I wonder what will have to go.”
Hundreds of miles away in a Virginia suburb of Washington, Nancy White fears what will happen at the Arlington Free Clinic, where she became director a year ago. The clinic relies on donations and volunteers and can accept only about 2,000 patients at a time. It knows of about 200 patients who have gotten subsidized ACA plans and shifted to private doctors. Many more never arrived at the clinic’s doors because of coverage they found through the law.
If the new president and the Congress end the subsidies or the marketplaces, the clinic would not have the capacity to take back newly uninsured patients, White said. “It’s what’s been what’s been keeping me up at night.”