Why Obamacare enrollees voted for Trump

CORBIN, Kentucky — Kathy Oller is so committed to her job signing up fellow Kentuckians for Obamacare that last Halloween, she dressed up as a cat, set up a booth at a trick-or-treat event, and urged people to get on the rolls. She’s enrolled so many people in the past three years that she long ago lost count.

Update: Watch interview with President Obama on the future of Obamacare

“Must be somewhere in the thousands,” she said to me one morning at a local buffet restaurant where she’d just finished an enrollment event with the staff.

The health care law has helped lots of people in Whitley County, where Oller works. The uninsured rate has fallen from 25 percent in 2013 to 10 percent today, according to data from the nonprofit Enroll America. Overall, Kentucky is now tied with West Virginia for the biggest increase in health coverage.

But Obamacare’s success in Whitley County and across Kentucky hasn’t translated into political support for the law. In fact, 82 percent of Whitley voters supported Donald Trump in the presidential election, even though he promised to repeal it.

Oller voted for Trump too.

“I found with Trump, he says a lot of stuff,” she said. “I just think all politicians promise you everything and then we’ll see. It’s like when you get married — ‘Oh, honey, I won’t do this, oh, honey, I won’t do that.’”

I spent last week in southeastern Kentucky talking to Obamacare enrollees, all of whom supported Trump in the election, trying to understand how the health care law factored into their decisions.

Many expressed frustration that Obamacare plans cost way too much, that premiums and deductibles had spiraled out of control. And part of their anger was wrapped up in the idea that other people were getting even better, even cheaper benefits — and those other people did not deserve the help.

There was a persistent belief that Trump would fix these problems and make Obamacare work better. I kept hearing informed voters, who had watched the election closely, say they did hear the promise of repeal but simply felt Trump couldn’t repeal a law that had done so much good for them. In fact, some of the people I talked to hope that one of the more divisive pieces of the law — Medicaid expansion — might become even more robust, offering more of the working poor a chance at the same coverage the very poor receive.

Byrd Pinkerton/Vox

The political reality in Washington, however, looks much different: Republicans are dead set on repealing the Affordable Care Act. The plans they have proposed so far would leave millions of people without insurance and make it harder for sicker, older Americans to access coverage. No version of a Republican plan would keep the Medicaid expansion as Obamacare envisions it.

The question is not whether Republicans will end coverage for millions. It is when they will do it. Oller’s three years of work could very much be undone over the next three years.

In southeastern Kentucky, that idea didn’t seem to penetrate at all — not to Oller, and not to the people she signed up for coverage.

“We all need it,” Oller told me when I asked about the fact that Trump and congressional Republicans had promised Obamacare repeal. “You can’t get rid of it.”

“I’m really having a problem with the people that don’t want to work”

Corbin is a small town in southeastern Kentucky, a place where cross-country truckers driving up and down I-75 will stop for the night. Its biggest tourist attraction is the first Kentucky Fried Chicken restaurant, which boasts an impressive collection of Harland Sanders memorabilia.

Sarah Kliff/Vox

Sarah Kliff/Vox

Oller has traveled around Corbin enrolling residents in health care plans since the coverage expansion started in 2014. And lately, she says, she’s watched the plans get more and more expensive.

“I like being able to give people good news, but it’s not always good news with Healthcare.gov, with the amount that premiums went up and the larger deductibles,” she says.

Premiums for midrange plans increased 22 percent nationally this year. That is, however, before the premium subsidies, which 80 percent of marketplace enrollees use — and which significantly lower the cost of coverage.

Narrow networks have become a problem in the area too. When Oller hosted an enrollment event at a hospital, she had to warn the enrollees that they couldn’t use their insurance at that particular facility.

Oller renewed a 59-year-old woman’s coverage (who asked her personal information be left out of this story) just after lunchtime on a Tuesday. She and her husband received a monthly tax credit that would cover most of their premium. But they would still need to contribute $244 each month — and face a $6,000 deductible.

The woman said she had insurance before the Affordable Care Act that was significantly more affordable, with $5 copays and no deductible at all. She said she paid only $200 or $300 each month without a subsidy.

The deductible left her exasperated. “I am totally afraid to be sick,” she says. “I don’t have [that money] to pay upfront if I go to the hospital tomorrow.”

Her plan did offer free preventive care, an Obamacare mandate. But she skips mammograms and colonoscopies because she doesn’t think she’d have the money to pay for any follow-up care if the doctors did detect something.

The woman said she only buys insurance as financial protection — “to keep from losing my house if something major happened,” she says. “But I’m not using it to go to the doctor. I’ve not used anything.”

The woman was mad because her costs felt overwhelmingly expensive. These are some of the most common frustrations with the Affordable Care Act. Surveys show that high deductibles are the top complaint; 47 percent of enrollees told the Kaiser Family Foundation they were dissatisfied with their deductible.

A study from the Commonwealth Fund earlier this year found that four in 10 adults on Affordable Care Act plans didn’t think they could afford to go to the doctor if they got sick. Fewer than half said it was easy to find an affordable plan.

But her frustration isn’t just about the money she has to pay. She sees other people signing up for Medicaid, the health program for the poor that is arguably better coverage than she receives and almost free for enrollees. She is not eligible for Medicaid because her husband works and they are above the earnings threshold.

Medicaid is reserved for people who earn less than 138 percent of the poverty line — about $22,000 for a couple. This woman understood the Medicaid expansion is also part of Obamacare, and she doesn’t think the system is fair.

“They can go to the emergency room for a headache,” she says. “They’re going to the doctor for pills, and that’s what they’re on.”

She felt like this happened a lot to her: that she and her husband have worked most their lives but don’t seem to get nearly as much help as the poorer people she knows. She told a story about when she used to work as a school secretary: “They had a Christmas program. Some of the area programs would talk to teachers, and ask for a list of their poorest kids and get them clothes and toys and stuff. They’re not the ones who need help. They’re the ones getting the welfare and food stamps. I’m the one who is the working poor.”

Oller, the enrollment worker, expressed similar ideas the day we met.

“I really think Medicaid is good, but I’m really having a problem with the people that don’t want to work,” she said. “Us middle-class people are really, really upset about having to work constantly, and then these people are not responsible.”

Oller had told me earlier that she had enrolled on Medicaid for a few months, right before she started this job. She was taking some time off to care for her husband, who has cancer and was in chemotherapy treatment. I asked how she felt about enrolling in a program she sometimes criticizes.

“Oh, no,” she said quickly. “I worked my whole life, so I know I paid into it. I just felt like it was a time that I needed it. That’s what the system is set up for.”

“I guess I thought that, you know, he would not do this”

Before I went to Kentucky, I did about half a dozen interviews with experts on why the state had voting so resoundingly for politicians who want to dismantle Obamacare.

I kept hearing the same theory over and over again: Kentuckians just did not understand that what they signed up for was part of Obamacare. If they had, certainly they would have voted to save the law.

Byrd Pinkerton/Vox

Kentucky had been deliberate in trying to hide Obamacare’s role in its coverage expansion. The state built a marketplace called Kynect where consumers could shop for the law’s private plans, in part to obscure the fact that it had anything to do with the unpopular federal law.

“We wanted to get as far away from the word Obamacare as we could,” Steve Beshear, the former Kentucky governor who oversaw the effort, says. “Polls at the time in Kentucky showed that Obamacare was disapproved of by maybe 60 percent of the people.”

I heard from Obamacare enrollment counselors who had seen this confusion play out firsthand, too. “When we’re approaching people about getting signed up on health care, one of the first questions they have is, ‘Is this Obamacare?’” says Michael Wynn, one of Oller’s co-workers. “So we would tell them, ‘No, this is not Obamacare. This is a state-run plan.’”

This was a story I heard a lot, but it was not the one that fit the Obamacare enrollees I met. All but one knew full well that the coverage was part of Obamacare. They voted for Trump because they were concerned about other issues — and just couldn’t fathom the idea that this new coverage would be taken away from them.

“I guess I thought that, you know, he would not do this, he would not take health insurance away knowing it would affect so many peoples lives,” says Debbie Mills, an Obamacare enrollee who supported Trump. “I mean, what are you to do then if you cannot pay for insurance?”

Mills and her husband run a furniture store. They used to buy their own health insurance in the early 2000s, but the premiums became unaffordable, surpassing $1,200. They had gone without coverage for two years, paying cash for doctor visits, until the Affordable Care Act began.

“It’s made it affordable,” Mills says of Healthcare.gov. This year, she received generous tax credits and paid a $115 monthly premium for a plan that covered herself, her husband, and her 19-year-old son.

Earlier this year, Mills’s husband was diagnosed with non-alcoholic cirrhosis of the liver. He is now on the waiting list for a liver transplant. Obamacare’s promise of health coverage, she says, has become absolutely vital in their lives.

Byrd Pinkerton/Vox

Her enrollment process wasn’t seamless; there were calls back and forth to different insurance companies and hospitals to make sure certain providers were in network. But she ultimately finished the process pretty happy, selecting a more robust plan for 2017 with a $280 monthly premium for herself, her husband, and her son.

As Mills waited to fill out the enrollment paperwork, we began to talk about her vote for Donald Trump one month earlier.

“We were wanting change,” she said. “We’re in an area with a lot of coal. When people aren’t in the coal mines, they’re not spending and buying in our area.” She said she thought Trump, a successful businessman, would have a better shot at fixing all that.

I asked her if she had followed the campaign and heard the candidates talk about repealing Obamacare. “I did, yeah,” she said. “That was the only thing I did not like about him.”

This was the conversation that followed, beginning with another question I asked:

Are you surprised how much Republicans are talking about repeal?

No.

Did you expect — do you think they'll do it, or do you think it'll be too hard?

I'm hoping that they don't, ’cause, I mean, what would they do then? Would this go away?

Yes, possibly.

The insurance?

It will go, if they repeal it. I mean, that's what they promised to do in so many elections.

Right ... so ... I don't know. ...

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?

Mills’s expectation that Trump would keep the Affordable Care Act, on the one hand, feel unrealistic: Of course Republicans would dismantle the law they spent six years campaigning against.

But it is also understandable: Legislators typically don’t dismantle large health coverage programs that serve millions. Since their creation in 1965, Medicare and Medicaid have certainly faced some opposition but never threats of outright repeal.

“I assumed it was impossible to repeal the ACA with 20 million people covered,” Larry Levitt, a health policy expert at the Kaiser Family Foundation, recently tweeted. “I may have been wrong about that.”

Donald Trump, meanwhile, made promises during campaign interviews that sharply diverged from his actual campaign stances. He promised, "I am going to take care of everybody,” during an interview with 60 Minutes — even though his health plan would leave 21 million without coverage.

The day after talking to Mills, I started to think about a headline I wrote for Vox a few years ago.

It was right after the Supreme Court upheld the health law in the King v. Burwell decision. “Obamacare’s final test: it survived the Supreme Court, and is here to stay,” the headline read. I quoted experts who said that because Obamacare had so many enrollees, of course Republicans wouldn’t dare dismantle it. One leading Obamacare advocate promised that “the ACA is a permanent part of the American health care system."

We used the same logic that Mills did. We thought, of course you can’t take away a program that millions of Americans rely on.

I spent election night frantically reporting and calling sources, trying to understand what parts of Obamacare Republicans could and couldn’t dismantle. I didn’t know at the time, nor had I devoted the necessary time to learn, until election night.

Mills was wrong about what Republicans would do to Obamacare. But then again, I write about it for a living. And I was wrong too.

“It was Russian roulette, but I felt that we needed change”

The Kentucky voters I spoke with constantly mentioned “change” as a reason they supported Trump.

“That man has a head for business,” one enrollee said. “He will absolutely do his best to change things.”

Still, Oller acknowledged she took a leap of faith with Trump.

“It was Russian roulette,” Oller said of her vote. “But I felt that we needed change.”

Byrd Pinkerton/Vox

Trump will almost certainly bring change to Obamacare. Republicans are moving quickly on repealing Obamacare and replacing it with a new policy. The current proposals suggest that policy will be better for the young, rich, and healthy — but worse for the poor, sick, or old. The type of people I spoke with in Kentucky are those at risk of being disadvantaged by some of the replacement ideas.

Consider the case of the 59-year-old who was frustrated with the cost of coverage under Obamacare.

The Republican plans might do some things that would be good for her. They would likely stop requiring insurers to cover a specific set of benefits, like the preventive care that she doesn’t use. That would drive down her premiums, but wouldn’t get her any closer to better health care access.

And there are plenty of changes that make it more likely her premiums would go up.

Right now she and her husband will receive $8,496 in subsidies toward their insurance premiums in 2017. Under the plan proposed by Rep. Tom Price, the Georgia Congress member whom Trump has selected to run the Health and Human Services Department, their subsidy would drop to $6,000.

Obamacare increases her tax credit if her income goes down. But the Republican plans don’t do that. The Price plan, for example, gives everyone over the age of 50 — whether that is this woman in Kentucky or Bill Gates out in Seattle — the exact same tax credit on the individual market.

Obamacare currently limits how much insurers can charge older patients like Ruby. It says that insurance companies can only charge its oldest patients three times as much as the youngest ones. But the Price plan would get rid of that requirement and let insurers charge older patients — who tend to need more health care — whatever they want.

Debbie Mills and I spoke for about an hour about Obamacare. By the end of the conversation, it had moved from me interviewing her to her asking a few questions about what might change and whether the coverage she would sign up for in a few minutes would still be valid.

Byrd Pinkerton/Vox

I ended up reassuring Mills that nothing would change for her coverage in 2017, and likely not 2018 — but that wasn’t a guarantee. I didn’t know what would happen either.

Our interview began to make her a bit nervous.

“You’re scaring me now on the insurance part,” she said. “I’m afraid now that the insurance is going to go away and we’re going to be up a creek.”

Watch: Repealing Obamacare could change millions of lives

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