CORBIN, Kentucky — There have been no marches against the Republican bill to repeal and replace Obamacare here. No raucous town halls. There was only one protest rally anywhere in the region. Photographs captured a solitary woman holding a sign.
In an area that stands to lose a lot of health coverage under the GOP’s American Health Care Act, the silence does not equal endorsement. It is a sign, instead, of disappointment setting in among a group of conservative voters who only months ago were bubbling with hope for Donald Trump’s health care plan.
The uninsured rate here in this rural swath of southeastern Kentucky has plummeted faster under the Affordable Care Act than any other area in the country. I visited the area last winter and talked to Obamacare enrollees who voted for Trump. They expected the president to repeal the law and replace it with something much better. “That man has a head for business,” one enrollee told me. “He will absolutely do his best to change things.”
I went back this spring just after the House passed the AHCA, the bill to repeal and replace Obamacare that would cause 23 million fewer Americans to have health coverage, according to Congressional Budget Office estimates. The optimism was gone. Resignation had replaced it.
“You know, thinking about it, I’m not even sure what I expected. I just thought it would miraculously work out wonderful for everybody,” Bobbi Smith, a 62-year-old Obamacare enrollee who voted for Trump, says. “So I guess maybe I didn’t put enough thought into what I would expect from a health care act.”
The souring on the Republican bill in a deep-red area of the country reflects the AHCA’s profound unpopularity nationwide. But the lack of protest also shows the strength of partisanship in the United States, which could prove a protective shield for Republican legislators in the 2018 midterms.
In southeastern Kentucky, the Obamacare enrollees I interviewed were disappointed — but they also weren’t mad that their Congress member, Hal Rogers, voted to pass it. They talked about all the other good things he had done for the area in his decades of service. They gave him the benefit of the doubt, expecting that he must have cast his vote to improve the economy or solve a budget issue.
This includes Kathy Oller, an Obamacare enrollment worker who supported Trump in the 2016 election. She feels let down by the Republican health care plan — “If they take the expanded Medicaid away, it really, really is gonna kill Kentuckians because they won’t have health insurance,” she says — and she’s already seeing other ways that Trump health policies are hurting Kentucky. Obamacare sign-ups, she said, were slower this year, as people in Kentucky were confused about whether the health care law still existed.
But Oller doesn’t regret her vote for Trump — “I don’t have regrets,” she says plainly — and she trusts that Rogers, whom she has also voted for, knows what he’s doing. She gets most her news from his weekly emails to constituents; she cites his arguments for why the law needs to be repealed.
This sentiment felt ubiquitous in Corbin. Obamacare enrollees I interviewed didn’t like the Republican plan, but they still trusted the Republican Party to do the right thing on health care.
They felt like they had picked a side, and now they were going to stick with it.
“It won’t be good for anybody”: the Republican health care plan would hit Kentucky especially hard
Perhaps no one stands to lose out more under the AHCA than the people who live in southeastern Kentucky.
In 2013, 20.4 percent of Kentuckians lacked health insurance. Now just 7.8 percent do. More Kentucky residents report having a regular source of health care, and fewer say they have skipped needed medical attention because of the cost.
The AHCA would reverse many of those gains. The bill the House passed would end the Medicaid expansion, a program responsible for three-quarters of Kentucky’s coverage gains.
It would reform the individual market in ways that would hurt southeastern Kentucky too. It would allow insurers to charge older enrollees significantly higher premiums, a practice limited under current law. This would hit Kentucky especially hard: 31 percent of Obamacare enrollees there are over 55 — well above the 20 percent national average.
You could see how all these changes would play out with someone like 62-year-old Clifford Hoskins. He’s retired and was recently diagnosed with black lung disease, the product of a three-decade career in the coal mines.
Hoskins signed up for Medicaid in early 2016 but recently transitioned to marketplace coverage when disability checks bumped up his income. He pays a $232 monthly premium for his plan, and receives a subsidy of about $700 from the federal government to cover the rest of the cost.
Hoskins liked his Medicaid plan, which paid for an ankle surgery last year. He likes his new marketplace coverage too. He takes at least four medications regularly to treat his black lung disease, some kidney issues, and depression. He describes his Medicaid plan as “the best insurance I ever had in my life.”
Under the AHCA, analysts estimate Hoskins’s premium would rise 24 percent as insurers would be able to charge someone his age a higher amount. His subsidy, meanwhile, would drop from $700 each month to $333.
Those two changes alone would more than triple his out-of-pocket premium, from $232 each month under Obamacare to $822 each month under the Republican plan.
“It’s going to at least take half, if not all, of my Social Security,” Hoskins says. “If I had to pay the full amount, that would not be good. That would put you back in poverty.”
There would be other changes at play too. Kentucky could waive out of Obamacare’s essential health benefits package, allowing insurers to cover fewer benefits. This would only lower premiums slightly, analysts say, and could be risky for someone like Hoskins. An insurance plan, for example, may decide to stop some of his prescription medications.
Hoskins had been reading a lot about the bill the House passed. He mostly reads things on the internet, starting at the AOL homepage, ever since he canceled his cable service a few months ago to save money. He doesn’t like what he’s seen.
“From what I’ve read on it, it’s not going to be good for anybody,” he says.
This all got him frustrated. He didn’t vote in the 2016 election — he was still in the hospital recovering from ankle surgery. There were certainly parts of the Trump agenda he liked, such as the president’s immigration policy. “I've not got anything again the wall,” Hoskins says. “I've got nothing against protecting our borders.”
But he says he’d be a one-issue voter when the next election rolls around if Republicans repeal the Affordable Care Act. “If they do away with this, there are going to be a lot of changes to my voting,” he says. “This is my biggest issue right now.”
To Hoskins, this was common sense: Of course votes would shift if Congress voted to end health insurance for millions of Americans. He predicted that Rogers’s vote to repeal Obamacare “probably changed every working person’s opinion [who is] on the Affordable Care Act.”
Actually, it didn’t. Most Obamacare enrollees I talked to didn’t like the Republican bill, but they didn’t think it would change their votes either.
“Maybe its a trade-off for all the stuff he’s done”: how partisanship protects Republican legislators
Kentucky’s Fifth Congressional District runs through the heart of Appalachian Kentucky. It is the fourth-most-Republican district in the entire country, according to the Cook Political Report’s Partisan Voter Index.
The district first voted Rogers into office in 1981, and has reelected him 18 times since. The last Democrat to run against him, in 2014, got 22 percent of the vote.
The places that benefited the most from Obamacare also tend to be some of the places with the most partisan voting records. If you zoom in on the 10 congressional districts that saw the biggest declines in uninsured rates, you will see eight are considered safe seats in the 2018 midterms. None are competitive enough for the Cook Political Report to rank them as toss-ups.
Political tribalism has become a major force in American politics — and is alive and well in the Kentucky Fifth. Voting Republican is just part of what it means to live in that area of the country. “Like my dad told me, this is a Republican county,” Hoskins says when I ask why he registered with the party.
Rogers’s office declined my request for an interview — but the Congress member felt like a constant presence during my trip to Kentucky. The local highway is named after him, and so is the water park. People like Oller relied on his emails to constituents to get information about Obamacare.
“This is Hal Rogers; he just puts it simple,” she says, when I asked her how Obamacare was going in her state. “Kentuckians have to choose between paying for health insurance and putting groceries on the table.”
Nearly all Obamacare enrollees expected Rogers to stick around. They weren’t mad about it either. Despite opposing his vote for the AHCA — and having an intensely personal stake in the matter — they felt he’s served the district well.
Michael Martin, a 47-year-old Obamacare enrollee, says he thought of Rep. Rogers’s AHCA vote as “a trade-off for all the other stuff he’s done. He’s brought jobs in. One of the places where I worked was one of the places he brought in.”
Martin likes his Obamacare coverage. He used to have a federal contracting job but is currently unemployed. He pays $77 each month and gets a $341 monthly subsidy from the government. He’s currently in treatment for thyroid cancer, which was diagnosed when he was on the Medicaid expansion about a year ago. He had a bypass surgery a few years ago, when he had insurance at work, and worries about that being categorized as a preexisting condition.
Martin has kept up with the health care debate. When we met in mid-May, he told me he was waiting for the new CBO number that would come out the next week. What he saw online made him think the new bill would be a raw deal for him.
“I saw a chart on the internet that showed the estimates of how much a person with preexisting cancer or cardiac problems would have to pay,” he says. “I fall into those categories. If you add them together, I’m like a double risk. The number was really up there, the premium.”
Martin wouldn’t tell me whom he voted for in the 2016 election; the people I met generally seemed more reticent to talk about which candidate they favored during this trip. But he did say he’d supported Rogers in the past and was currently puzzling over his Congress member’s vote. He wasn’t necessarily mad, more confused. I asked him whether he thought Rogers had the best interests of Kentuckians at heart.
“He’s gotta know, right?” Martin responded. “Well, he’s gotta know, but I can’t see the reasoning why he voted ‘yes,’ you know?”
Bobbi Smith hadn’t followed the health care debate as closely. She pays $330 each month for her Obamacare plan and gets a $447 subsidy from the government. She’s happy with her insurance, which worked well when she was diagnosed with breast cancer last January.
Smith didn’t like the idea that AHCA could raise her premiums just because she’s older. “The higher premium for older people is generally a gripe,” she says. “And for people with preexisting conditions, that’s terrible. [It would] be really hard for them.”
But Smith started kicking around the idea a bit more, and began to come around to the Republican plan. “You can’t buy insurance for anything else that’s already damaged either, if you think of it that way,” she says. “You can’t wreck your car, then go buy insurance. ... It would be wonderful if they could just be insurance at the same price as everybody else...”
She paused for a moment, and then says, “I don’t see that being feasible.”
Smith didn’t like the changes we talked about in the Republican plan — but she wasn’t especially worried about them either. She understood that her premium might go up and her subsidy could go down. But she felt like she had picked a side in America’s political debate, and for now, she is going to stick with it.
“We choose which party we place our values with,” she says. “We’re supposed to trust them to do for us, you know, what our party stands for.”
Republicans’ vote for an unpopular bill will test the limits of partisanship
Partisanship is the best predictor of what people think of the Affordable Care Act, even better than whether someone has benefited from the law.
“Partisanship trumps personal experience,” says Mollyann Brodie, who runs the Kaiser Family Foundation’s monthly tracking poll. “Your party affiliation tells me whether you think you were helped or hurt by Obamacare, even if you don’t have individual insurance.”
The recent uptick in support for Obamacare doesn’t reflect Republicans suddenly reconsidering their opinions. Brodie says that when you dig into the numbers, Republicans are just as opposed to Obamacare as they have been for years. Instead, you see Democrats who were lukewarm supporters suddenly becoming more fervent proponents.
But partisanship also has limits. Conventional wisdom has suggested that Trump’s core supporters would stick with him through thick and thin. FiveThirtyEight’s Nate Silver suggests that has become less true ever since the American Health Care Act passed. The ranks of voters who “strongly support” the president has dropped consistently since mid-May.
Silver’s argument rang true in Corbin. The voters who were willing to defend Hal Rogers were less willing to give Trump the same deference. They voted for change, for the candidate who promised to support a health care plan that covers everybody. They felt let down.
“It doesn't look like Trump's going to listen to us,” Oller told me over eggs at Cracker Barrel on a rainy Thursday morning. “I kind of figured he would listen. He would listen to everybody and try to work it out. But he’s got too many other fish to fry now.”
The politics of repeal are, ironically, most dangerous for Republicans who represent districts with fewer Obamacare enrollees
Contrast the Kentucky Fifth with California’s 49th Congressional District, which Rep. Darrell Issa, a Republican, currently represents. Issa’s district is relatively high-income and had a high insured rate before the Affordable Care Act passed. Gains in coverage have been relatively modest.
But Issa has been besieged by protesters at his office and at raucous town halls. The Cook Political Report rates his district as a “toss-up” in 2018.
Issa won his district narrowly in 2016, by just about 5,000 votes. The place he represents, a swath of Southern California coastline running through San Diego County, has lots of angry Democrats. Brodie’s research has found an intensity gap between the parties: Democrats tend to strongly oppose the AHCA, whereas Republicans are lukewarm in their support.
“What we always saw on the ACA was that Republicans were strongly opposed and Democrats were less strongly in favor,” Brodie says. “Now our polling is starting to show a mirror image of that.”
Obamacare enrollees probably won’t rise up en masse to oust Republicans such as Issa. But the vote could haunt those members by driving angry Democrats to turn out in greater numbers — and persuading some dismayed Republicans not to turn out at all.