Jake Tibbets untangles the Conservative dilemma: keep Obamacare, or lose the support of rural America.

Merely hours after being sworn in as the forty-fifth President of the United States on January 20th, Donald J. Trump began to clear a path leading towards the full repeal of the Affordable Care Act. In his first official act as president, Trump signed an executive order commanding all federal agencies to do all that is possible to delay or waive all requirements of the Affordable Care Act that impose regulatory or financial burdens on states, taxpayers, or businesses. The executive order states that Trump will advocate for the “prompt repeal” of the landmark legislation and that the federal agencies should prepare to “afford the states more flexibility and control to create a more free and open healthcare market.”

Trump’s actions have received the implicit backing of congressional Republicans from all factions of the party. In early January, the House of Representatives voted 227 to 198 and the Senate voted 51 to 48 in support of a bill that would allow Republicans to use a process known as “budget reconciliation” to quietly roll back funding for provisions located in the Affordable Care Act. Though it is incredibly unclear what a repeal may look like, it is very likely that the three largest provisions of the Affordable Care Act—Medicaid expansion, the individual mandate, and the establishment of a subsidized private marketplace—will be among the first to go.

Trump Won Because He Spoke for the Economically Anxious

President Trump was commended by fellow Republicans while on the campaign trail for demonstrating a unique ability to tap into a growing feeling of economic anxiety held by many rural Americans. Trump’s support in the November 8th election came from older males without college degrees, a demographic that, though once dominant in the American economy, has suffered setbacks as a result of trends of neoliberalization and globalization. His campaign, which was centered around promises to “tear up” trade deals like NAFTA and to bring jobs back from foreign nations, brought comfort to a demographic that felt as though it was being left behind. It was this support that carried Trump to victory in critical swing states such as Pennsylvania, Wisconsin, Ohio, and Michigan.

Jed Kolko of FiveThirtyEight noted immediately following the election that Trump won most counties in which a large percentage of jobs are vulnerable to outsourcing or automation. Ben Casselman of FiveThirtyEight wrote in a similar study that the slower a county’s job growth has been since 2007 (the beginning of the Great Recession), the more it favored Trump. He continued to provide examples of how counties’ economic standing dictated how they voted: “More subprime loans? More Trump support. More residents receiving disability payments? More Trump support. Lower earnings among full-time workers? More Trump support.” Trump’s support, he says, came from “where… economic prospects are on the steepest decline.”

Obamacare Has Been a Source of Security, Not Disorder

What both the Trump administration and Republicans in Congress seemingly fail to realize, though, is that the Affordable Care Act has significantly benefitted the communities that enabled the Republicans to win a majority in the House of Representatives in 2010, a majority in the Senate in 2014, and the presidency in 2016.

By going forth with a plan to repeal the Affordable Care Act without solidifying plans to replace it with a system that guarantees coverage for all Americans, the Republican Party risks losing the support of many rural Americans during the 2018 midterm elections.

White voters who make less than $50,000 a year, for example, have made significant gains in terms of health insurance coverage since the passage of the Affordable Care Act in 2010. Though it has often been reported that rates of uninsurance decreased more for people of color than white people during the Obama presidency, this is mostly because people of color are more likely to fall in lower income brackets.

When we stratify by income and look solely at those who make less than $50,000 a year, it becomes clear that white Americans gained coverage at notably high rates. According to the Current Population Survey Annual Social and Economic Supplement, the proportion of uninsured, low-income white people in America decreased by 8.6% between 2013 and 2015 alone, outpacing both the overall rate and the rate amongst low-income people of color. In other words, the Affordable Care Act did more to improve the standing of low-income white Americans, many of whom lent their support to Donald Trump in the 2016 presidential election, than any other group.

Rust Belt Voters Overwhelmingly Support Public Insurance

Looking more closely at states that President Trump won in November, it becomes clear that the Affordable Care Act has been far more important in the rural communities that brought forth his victory than his campaign rhetoric may have suggested. In Appalachia, the Affordable Care Act has proven essential in allowing state governments to rebuild collapsing public health systems that have become overburdened by new health concerns.

In West Virginia, a state that has been burdened by coal-related health issues, pollution, and the highest rate of drug deaths in the nation, the Affordable Care Act has proven essential in expanding Medicaid services to underpaid coal miners. In Kentucky, a state that is facing many of the same problems as West Virginia, 63% of citizens have a favorable view of Medicaid expansion, 71% of citizens have a favorable or neutral view of Kynect (Kentucky’s exchange program, modeled after the Affordable Care Act), and 72% of citizens, including 54% of Republicans, would prefer for Medicaid coverage to continue as it exists today rather than for it to be scaled back to cover fewer people.

While Trump has stayed true to his promises to support rural America by fighting against the disappearance of well-paying, union-protected jobs, the new presidential administration seems to have no desire to fight against the erosion of employer-sponsored health insurance. In 1999, 67% of Americans were enrolled in employee-sponsored health insurance programs; by 2014, that number dropped to 56%. It has been the responsibility of public insurance to pick up the slack brought forth by the greed of the corporate class. While it is true that, as Trump has stated, the costs of premiums and prescription drugs remain quite high, it is also true that, because of the Affordable Care Act, millions of poor Americans have gained health care coverage at little or no cost during a crucial time in which employers are less than likely to wholeheartedly support paying for their employees’ plans. In rural America, for example, more than one-quarter of all citizens rely on Medicaid or similar forms of public insurance to cover their most basic health care needs. Furthermore, Obamacare, besides directly expanding Medicaid coverage, has been crucial in directly funding public health initiatives in rural parts of the country such as efforts to develop new community health centers and missions to send urban-based physicians to rural communities. Regardless of what Republicans in Washington say, the Affordable Care Act has changed the lives of poor Americans in deep-red states for the better.

By Repealing the ACA, Republicans Will Jeopardize Their Electoral Future

By undoing all the progress made in regards to health care coverage over the course of the past few years, though, Republicans risk placing themselves in a state of electoral insecurity.

Though Republicans have introduced plans to “replace” the provisions included in the Affordable Care Act, the party has failed to coalesce around one blueprint. All but one of these plans would not only diminish subsidies introduced by the Affordable Care Act but would also put Medicaid in a stranglehold; such an act could serve as the final blow for the weak, newly insured communities that exist at the center of the anti-Obamacare narrative to which the Republican Party has clung. Though the immediate economic benefits that could come from the repeal of the Affordable Care Act could positively affect young, healthy Americans of solid financial standing, it would unequivocally damage the lives of the vulnerable residents of rural counties whom the Republicans claim to wish to defend.

According to a study conducted by The Economist soon after the results of the 2016 presidential election were made available to the American public, the health of a county was the third most important indicator, besides race and education, of whether a county that voted for Obama in 2012 would vote for Trump in 2016. Though there may not be a direct causality, as poor health levels are directly tied to rurality, which is itself tied to a certain level of whiteness and a lack of education, it is undeniable that many of the counties that voted for Donald Trump and other Republicans on November 8th have been forced to confront the effects of increased rates of suicide, heart disease, liver failure, and opioid addiction.

Though it is undeniably true that the Affordable Care Act has not gone far enough in addressing how to ensure that all Americans, regardless of economic standing, be granted access to affordable health care, the Republican plans for repeal do little more than restricting coverage, access, and availability of high-quality, affordable health care.
If the Republican Party has any desire to hold onto the Senate, the House of Representatives, and the White House, it is in its best interest to spend far less time orchestrating ways to launch entirely partisan attacks on the legacy of the Obama administration and to spend far more time figuring out ways to constructively assess how to ensure that the most vulnerable Americans receive comprehensive health care coverage.

Jake Tibbetts

Jake Tibbetts is a Yale Young Global Scholar 2016. He is an avid political organizer in his community, serving as an organizer on multiple state legislative campaigns.

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