I spent Thursday night in Harrisburg, Pennsylvania, conducting focus groups with Obamacare enrollees to get a sense of what they think of various Republican ideas to change the ACA. What I found surprised me.
I worked with the research firm PerryUndem, which set up two groups. One was exclusively Medicaid enrollees. The other was Trump voters enrolled on Obamacare programs (either Medicaid or the marketplace). In total, we talked to about 14 participants for three hours.
Participants sounded positive on some Republican changes (age-based tax credits, for example, as well as Medicaid reform) but very negative on one specific proposal: a continuous coverage requirement.
We’re still conducting additional focus groups, and I’ll report on those more in the future. For now, here are my three biggest takeaways from the early research:
1) Trump voters liked age-based tax credits. Nearly every Republican plan (including the one leaked last Friday) would end Obamacare’s income-based tax credits, which provide more help to the lowest-income Americans and phase out for higher earners. Currently, those earning above 400 percent of the poverty line ($47,550 for an individual or $97,200 for family) get no help.
Republican plans would provide age-based tax credits that anyone who purchases their own insurance would receive, regardless of how much they earn.
The Trump voters we ran this by were really enthusiastic about that idea. Some likely earned enough to benefit from the proposed change; others did not. But that didn’t seem to matter. What voters liked was the universality of the idea, that everyone would get the same thing.
“Everybody who has insurance should get a benefit; everybody despite income should be encouraged to take care of their health,” Eric, a 40-year-old business owner and former Obama voter, said.
I offered up the idea that someone like Bill Gates would get financial help with his insurance, even though he is incredibly wealthy. “Even though Bill Gates could afford it, Bill Gates could get some rare disease we don’t have a cure for right now, and his medical bills could wipe him out, for all we know,” Sharon, a 48-year-old homemaker enrolled in Medicaid expansion, responded.
2) Trump voters were down on the continuous coverage provision. It is clear that the individual mandate is not popular. So the Republican plans have an alternative: They require Americans to maintain continuous coverage or else face higher costs for preexisting conditions when they do return to the market.
The leaked plan from last week, for example, would let insurers charge those who don’t maintain continuous coverage 130 percent of the base premium for a full year, before they could return to the standard rate.
This did not get a positive reception. The group got hung up on the idea of someone losing their job and suddenly not being able to afford insurance. Why should that person get penalized, they kept asking.
“Life happens, and you may be making $100,000 per year but all of a sudden your company goes out of business and you’re left with nothing, and it’s not your fault that you have the preexisting condition and you don’t have the insurance,” Denby, an unemployed 54-year-old, said.
“I don’t like that idea,” Robyn, a 34-year-old dental assistant, said. “Now you’re paying seven times the amount when it’s not your fault you were let go to begin with.”
3) Medicaid enrollees were surprisingly open to Republican reform ideas. In our Medicaid focus group, we tested out some ideas that Republican governors have recently proposed for reforming the public entitlement programs. This included a monthly premium between $1 and $15 as well as a work requirement in order to qualify for the program.
I had expected Medicaid enrollees to be pretty negative on these proposals, which would increase financial burdens on them. But it was the exact opposite. This group, which included a mix of Trump voters, Clinton voters, and nonvoters, generally liked the idea. They felt there was currently a stigma around the program — that, as one Medicaid enrollee put it, “everybody on Medicaid is lazy and doesn’t work.”
“It gets rid of that stigma because they can say that’s not true, they do at least 20 hours of employment activity,” Kyle, a 34-year-old bank teller and Medicaid enrollee, said.
“That’s pretty good,” Will, a 50-year-old plumber and Clinton voter, said of the work requirement idea. Monica, a 37-year-old construction worker, liked it because volunteer work could fulfill the requirement. “You could go knit with old ladies; I mean, you don't have to be out, like, working,” she said.
We asked the group what they thought of a $1 to $15 premium, an idea that Kentucky Gov. Matt Bevin has proposed in a waiver currently pending with the Trump administration. Here’s what we heard back from people who currently use the program:
Eileen, 59-year-old teacher: That's affordable. That's reasonable.
Monica, 37-year-old construction worker: Yeah.
Mike Perry, PerryUndem researcher: Is that affordable?
Kyle, 34-year-old banker: Well, it's accountability, too.
Eileen: Right.
Mike: All right, are you for this or against this idea? Would you be okay with it or not?
Eileen: Yes, if nothing else changed.
Will, 50-year-old plumber: If it was effective, yes. No problem.
We’re still conducting more focus groups where we’ll continue to ask similar questions but also work in details from the leaked draft Friday. Stay tuned for more results in the next few weeks.
Leaked docs outline GOP governors’ Medicaid demands
At the National Governors Association’s annual winter meeting, I obtained two key documents that show where the repeal debate is headed:
Internal Republican Governors Association documents show GOP demands. Republican governors are undecided on how far they want Congress to go in overhauling Medicaid, internal documents obtained by Vox show. Read more here.
In a private meeting, governors saw a presentation suggesting GOP plans would cause millions to lose coverage. The presentation estimated what would happen in a hypothetical Medicaid expansion state with 300,000 people in the individual market. In the individual market, enrollment would fall 30 percent and 90,000 people would become uninsured. The report does not make national projections for coverage declines, and we don’t know the exact size of the individual market. We do know it is somewhere in the tens of millions — so these numbers do indicate that this particular GOP proposal would leave millions of Americans without coverage. Read my story on the report — and the report itself here.
Trump meets with insurers, says “nobody knew” health care could be complex
President Trump’s morning included back-to-back health-focused meetings. It started with a 9:30 am sit-down with governors, followed by a 10:30 “listening session” with the executives of top health insurance firms.
Great meeting with CEOs of leading U.S. health insurance companies who provide great healthcare to the American people. pic.twitter.com/s2NMVMvQq3
— Donald J. Trump (@realDonaldTrump) February 27, 2017
It was one remark the president made to the governors that has gotten the most attention. “We have come up with a solution that’s really, really, I think, very good,” Trump said. “It’s an unbelievably complex subject. Nobody knew that health care could be so complicated.”
Both halves of this quote are startling in their own right. There is little evidence that the Trump administration has a repeal-and-replace proposal in hand — although governors who met with him reported one is in the works. All policymaking at this point seems to be happening in Congress, not at the White House.
But it is really the second half of that quote that made health policy experts cringe. Anyone who has worked on health policy — whether an insurance executive, a member of Congress, or a think tank economist — knows that health care is incredibly complex. This is one key reason that it took Democrats 15 months to pass the Affordable Care Act — and a key reason Republicans are currently struggling with the issue now.
Chart of the day
Governors saw this chart in a closed-door Saturday meeting. It was part of a presentation from the consulting firm McKinsey, and it shows how GOP health plans would affect a hypothetical state with 300,000 people in the individual marketplace. McKinsey estimates that 90,000 people would drop out of the individual market because of the less generous tax credits, meaning the market would shrink by 30 percent.
A spokesperson for McKinsey emailed Sunday to add that as Republican plans evolve, so will their numbers.
“The illustrative example shows the potential effects of a single subsidy proposal change based on 2015 methodology that was publicly available,” the McKinsey statement said. “It must be viewed in full context with the range of potential changes states may choose to take.”
Kliff’s Notes: Today’s top 3 health policy reads
“A divided White House still offers little guidance on replacing Obamacare”: “Within the administration, aides are debating how far and fast Republicans can afford to move when it comes to undoing key aspects of the ACA. Several people in Trump’s orbit are eager to make bold changes to reduce the government’s role in the health-care system. Other White House advisers, according to multiple individuals who asked for anonymity to describe private discussions, have emphasized the potential political costs to moving aggressively.” —Juliet Eilperin and Amy Goldstein, Washington Post
“GOP’s New Plan to Repeal Obamacare: Dare Fellow Republicans to Block Effort”: “GOP leaders hope to push through Congress along party lines a bill now being drafted in the House that would repeal major chunks of the health law, according to Republican aides and lawmakers. The move would require use of the ‘reconciliation’ process in the Senate, which lets measures that are generally budget-related pass with a simple majority instead of 60 votes.” —Louise Radnofsky, Kristina Peterson, and Stephanie Armour, the Wall Street Journal
“Kasich: GOP may need Democrats to ensure coverage for millions”: “Ohio Gov. John Kasich thinks House Republicans will need to reach out to Democrats in order to pass health-care reform that won’t cut off coverage for millions of people. But he’s not sure they will. Speaking on CBS’s ‘Face the Nation’ on Sunday, the former Republican presidential candidate said too many House Republicans are determined to repeal all parts of the Affordable Care Act on principle.” —Mike Murphy, MarketWatch