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These GOP voters hate Obamacare. They hate the new replacement bill too.

The complicated balancing act of an Obamacare replacement.

Trump was right: health care is very complicated.
Mark Makela/Getty Images

Donna and Earl Eck took a bus from Altoona, Pennsylvania, to Washington, DC, on Tuesday to spend the day rallying against Obamacare. They were whisked to the capital by Americans for Prosperity, a Koch-backed group that has spent tens of millions of dollars opposing the Affordable Care Act.

When they headed to DC, the Ecks had simply planned to stomp around the Capitol, meet other Obamacare opponents, and make their voices of ACA dissent heard. There was just one wrinkle in their plan: The night before the rally, the Republican Party put out an Obamacare replacement plan they can’t stand behind either.

The Ecks are among the millions of Americans who dislike the ACA and feel it’s not working for Americans, or even that it’s harming them. But the proposals their party is coming up with, like the new American Health Care Act, do not address their grievances, and may actually make some of them worse.

Donna is a retired teacher and Earl is a retired nurse. They've got gold-plated health insurance. But the Tea Party activists and Trump supporters hate Obamacare, especially what it’s done to their family members.

“I have a nephew, and he had a $13,000 deductible [after Obamacare],” Earl told me this morning, near the Capitol. The nephew, he said, had to get a second job in a car factory to be able to afford his health care.

Donna also hates the ACA and worries the government is getting in the way of which doctor her children can see. When her kids were little, she’d go to the doctor and he’d trust Donna to know what was best for their care. Obamacare changed all that. “It’s [choosing your doctor] and even determining the tests you should have,” she said. “You should be able to control your health care.”

But the new House GOP bill, they say, just trades one kind of subsidies and government mandates for another.

“The Republicans have to completely replace [Obamacare],” Earl said.

The Republican challenge: appeasing the Trump supporters who gained coverage while not alienating all those who hate Obamacare

Emerson Slain, a Louisiana Republican, says he’s been harmed by Obamacare. He doesn’t want to lose his Medicaid expansion, though.
Carlos Waters/Vox

The Ecks represent one side of the balancing act Republicans must navigate, among supporters of President Trump, when it comes to replacing the law: appeasing those who feel the law trampled on their individual rights and freedoms, or drove their premiums to unaffordable highs.

The other half are the Trump supporters who gained coverage they like and want to keep under Obamacare.

Emerson Slain, a nonprofit worker and Republican in Ferriday, Louisiana, says he’s been harmed by Obamacare. But like the protesters in Washington on Tuesday, he’s not sure the replacement plans will improve matters. He also gained coverage under the law that he doesn’t want to see disappear.

Slain was paying for private health insurance when he finally became eligible for Medicaid under Louisiana’s expansion last summer. He got his Medicaid card in the mail, he says, and quickly became ensnared in an Obamacare-induced bureaucratic nightmare: He was losing his vision because of a partial retinal detachment, a complication of his Type 2 diabetes, and needed an eye operation to save his eyesight.

But the doctor he had lined up 12 miles from home happened to be across the state border, in Natchez, Mississippi. And because Slain was now on the Louisiana Medicaid expansion, the doctor would no longer accept his new health insurance.

It took Slain six months to find a new doctor in his state, during which time he says his vision worsened. When he finally did locate a clinic that could help him, the doctor happened to be in Baton Rouge, Louisiana. So instead of making the short drive across the border to Natchez for the operation, he had to commute 107 miles.

“I am still pissed off with the former president about Obamacare,” Slain says. “I should have had my surgery last year.”

So what about the new replacement plan? Is it any better? “I think it’s Obamacare lite,” he said. He’s particularly critical of the age-based subsidies, which he views as another entitlement program.

On the other hand, Slain doesn’t want Medicaid expansion to end in 2020, as Republicans are now proposing. That’s the part of the law that will directly impact him, and perhaps limit his health care — however imperfect — or take it away.

The current Republican replacement plan, like its previous incarnations, might particularly punish Trump supporters enrolled in Obamacare. Illness was a key indicator of Trump support. As the Economist showed, when you parse county-level data on life expectancy, obesity, diabetes, heavy drinking, and regular physical activity, counties in worse shape were particularly amenable to Trump’s message. Other analyses have also found that Trump’s rise seems to be linked as much with poor health as with economic troubles or other measures.

With the replacement plan’s mixture of cuts to Medicaid, freezes on Medicaid expansion by 2020, and removal of income-based tax subsidies for health insurance, it will almost certainly favor people who are healthy and high-income, and disadvantage those who are sick and low-income (though we don’t yet have estimates on how much it’ll cost or how many people it will leave off insurance). In other words, it’ll almost certainly hurt Republicans like Emerson Slain.

While campaigning, Trump vowed to address some of America’s health woes. He said he’d end the opioid crisis, promised “insurance for everybody,” and to keep some of Obamacare's popular provisions, such as the protections for people with preexisting conditions, while getting rid of the unpopular parts of the law, like the individual mandate. How the GOP manages to deliver this complicated mixture, in a politically expedient way that satisfies constituents, is shaping up to be their defining challenge.

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