PINKERTON: The Fate of Obamacare in the Trump Era — What the Middle Class Wants, It Will Get

AP Photo/ Evan Vucci

Second in a series…

In the first installment of this series, we explored the past fight over Obamacare and the coming fight over Trumpcare.  Of course, it will be a while before we know exactly what Trumpcare will look like; the details are still being worked out.


And yet even now, we can make a general prediction:  When all is said and done, the Trumpcare that replaces Obamacare will reflect the interests of Trump voters, and the middle class.  It will thus be different from past efforts, coming from both sides of the aisle, to devise a workable form of health insurance.   

1. The New Republican Party 

So now let’s start by taking a look at the Trump vote and, more broadly, the middle class.  As President Donald Trump likes to say, he’s the messenger of a movement, and here are some key facts about that movement—specifically, about the 62,980,160 Americans who voted for Trump.

The most obvious point is that the Trump-ified GOP is no longer—if it ever was—the “party of the rich.”  Even Democrats, if they are honest, have to admit that much.  Indeed, there’s been something of a class-partisan inversion in our national politics.     

So Republican officeholders might do well to look closely at their voters, including the many new GOP voters.  In 2016, of the 10 states (including the District of Columbia) with the highest median income, nine voted for Hillary Clinton.  Conversely, of the 10 states with the lowest median income, nine voted for Trump.  We can pause to note that Trump voters themselves are typically not impoverished, and yet, many of them live in relatively poor states, where they find themselves sandwiched in the middle.  According to the nationwide 2016 exit poll, Clinton won the poor, as well as the rich, while Trump won those in between.  

And it’s this Middle America, of course, that feels most besieged.  As Trump said in his January 20 inaugural address, it’s because of globalization that “the wealth of our middle class has been ripped from their homes and then redistributed across the entire world.”

Indeed, the effects of globalization, which have favored the few and hurt the many, are stark: According to a post-election study by the liberal Brookings Institution, the 472 counties that Clinton carried last year accounted for 64 percent of the nation’s wealth, while the 2584 counties that Trump carried accounted for the remaining 36 percent.  And the people in those “blue dots” know who’s been good to them.  Thus it was, for instance, that Clinton got 84 percent of the vote in the rich globalist citadel of San Francisco and 87 percent of the vote in the equally affluent Manhattan.  

Meanwhile, in the same election, Trump won 118 of 120 counties in Kentucky, which ranks 47th in the country in terms of median family income.  Indeed, in the Bluegrass State’s iconic Harlan County, scene of so much coal-mine tragedy and strife over the last century-and-a-half—only now to find itself, along with the rest of coal country, in the crosshairs of the affluent global greens—Trump won with almost 85 percent.  

Moreover, if we drill down in another gritty state, Michigan, we can see even more evidence of how the political deck has been shuffled.  As we all know, Trump won the predominant working-class areas of the Wolverine State, thereby becoming the first Republican presidential candidate to win there since 1988.

Notably, Trump won blue-collar Macomb County, just outside of Detroit, home to a population of more than 850,000.  Macomb was long a stronghold of the United Auto Workers, and then, in the 1980s, it became notable as a new fortress of “Reagan Democrats.”  Then many of those Reagan Democrats reverted back to Bill Clinton and his party in the 90s; Macomb even went for Barack Obama in 2012, preferring him over Michigan-born-and-raised Mitt Romney.  And yet, in 2016, Trump carried the county by nearly a dozen points.  

In the meantime, as Trump was carrying the blue collars, Hillary was carrying the white collars.  Also just outside of Detroit is the more affluent Oakland County, home to more than a million.  Oakland has traditionally been the largest Republican county in the state, and yet, last year, Clinton carried it by more than eight points.  Thus we see that the nationwide political inversion—the rich now for the Democrat, the middle now for the Republican—was also true in Michigan.

And this is, to put it mildly, an historic shift.  In recent decades, other Republican presidential candidates, such as Richard Nixon and Ronald Reagan, have carried Michigan, but their coattails were insufficient to win many House seats.  And yet today, in the 115th Congress, Republicans now control nine of the state’s 14 Congressional districts.

So this is the new Republican Party.  As Trump said of the GOP in May, “Five, 10 years from now—different party. You’re going to have a worker’s party.” 

In fact, we didn’t have to wait even that long, as the 2016 results show.  In the post-election words of Trump campaign adviser Steve Moore, “Just as Reagan converted the GOP into a conservative party, Trump has converted the GOP into a populist working-class party.” 

Thus we can now look at a county-by-county election map and see: There are rich blue dots (and also, poor blue dots) amidst a broad swathe of middle-class red. 

2. Goodbye Obamacare; Hello, Trumpcare 

Okay, so now to healthcare—or, more precisely, health insurance.  As I have argued here recently, health itself is sometimes far different from health insurance.   

Yet in the meantime, Trump campaigned on getting rid of Obamacare, as did Republicans in Congress.  So it’s a near certainty that the Affordable Care Act of 2010 will cease to exist.  And yet what will replace it? 

Stipulating that the new plan is still unannounced, here’s an overall thesis statement for your consideration: In the long run, policy follows politics.  That is, people vote their policy interests, as they see them, and politicians had better be respectful of those interests.  And if they aren’t, then the voters will catch on quickly enough and throw them out of office.  And so it is, too, with healthcare. 

So now we can add a further point: How you see healthcare depends in large part on where you stand economically.  This is not an argument about class; this author is hardly a class warrior.  Instead, it’s a simple observation: People at different income levels have different experiences with the health system.  For the rich, health insurance is no problem; they can afford all the healthcare they need or want, with or without health insurance.  And for the poor, health insurance is also not an issue; they get it from the government, mostly through Medicaid, but also by simply coming into a hospital emergency room.  (Under a federal law in place since 1986, the ER has to take of anyone, regardless of ability to pay, or of citizenship status.)  

Stuck in between, of course, is the middle class.  Especially these days, when companies are shedding their benefit packages, families have to scramble to buy adequate health insurance, dodging all the bureaucrats, both public and private.  In fact, just the other day here at Breitbart, Ann Coulter wrote about all the vexations she experienced in trying to buy private health insurance. 

Moreover, not all healthcare is equal.  In fact, health and longevity vary strikingly by income.  Not surprisingly, those at the top do the best; according to a 2015 report from the federal National Academies of Science, Engineering, and Medicine, a 50-year-old man in the upper income quintile, or category, can expect to live another 38 years; those in the upper-middle quintile can expect to live another 37 years.  Meanwhile, those in the exact middle can look forward to another 33 years.  Those in the lower-middle have another 28 years, while those at the bottom have another 26 years.  So we can see the wide disparity—a five-year gap of longevity between the top and the middle, and a dozen-year gap between the top and the very bottom.  (Statistics for women show the same income-skew, top-middle-bottom, although women typically live a couple of years longer than men.)

So what’s causing this lifespan gap?  Yes, the rich can afford all the bells and whistles of “concierge medicine” and Number One-rated hospitals, and yet as physician-author Atul Gawande wrote recently, the biggest single variable in health outcomes is a regular visit to a general practitioner; it’s the family doctor, knowing the patient, and his or her medical history, who can usually spot, for example, the difference between a heart attack and an allergic reaction.  As Gawande explains: 

States with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke.  Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health.

In other words, it’s the ongoing relationship between the healthcare provider and the patient that does the most to save lives—that’s something to keep in mind as one ponders insurance plans and provider networks.  

All right, so how might all this be reflected in a post-Obamacare health plan?  We can start by recalling the Republican critique of Obamacare and, before that, of Clintoncare—that being the failed effort by Hillary in the 1990s.  Republicans always said, “Don’t let a bureaucrat get between you and your doctor,” and they had a point—a lifesaving point. 

Such blunt wisdom is sure to inform the Trump administration’s health plan.   Indeed, the middle class can take comfort in the regular-joe background of many key Trump advisers.  The blue-collar origins of Stephen K. Bannon, son of a Richmond, VA, telephone lineman and splicer, are well known.  

Yet less well-known is the life story of another top White House aide, Anthony Scaramucci; he is the son of a Long Island construction worker who went on to earn a fortune as an investor.  Recently, Scaramucci recalled  what it was like to be on the campaign trail with Trump, mingling with the crowds of supporters: 

There was a common thread . . . It was, “There was a factory here that closed down four years ago,” “I’m on some level of governmental dependency,” “I’m super-worried about my children,” “[Trump’s] here, he’s promised to come up with solutions to get jobs back in my neighborhood.”

Trump’s goal, of course, as he said in the inaugural, is to create policies that wean people from any sort of dependency.  His mission is “to get our people off of welfare and back to work.”  And yet in the meantime, we must be mindful of the grievous costs that globalization—and other kinds of liberalism—have inflicted on places such as Harlan and Macomb counties.  

The Trump advisers know all about this, because they have witnessed the damage, up close.  The same Scaramucci also said that when he talked with Trump fans, he had flashbacks to his own modest upbringing; he would say to himself, “Oh my God, these were the people I grew up with.”

Most importantly, there’s the 45th president himself.  As Scaramucci observed, Trump, for all his wealth, never lost track of Middle America: 

The great irony of this story is that a billionaire real estate developer living in a tower in New York City was in closer touch with the people I grew up with than I was. 

Indeed, Trump is the only commander-in-chief to have been inducted into the WWE Hall of Fame; he has long been friends with the wrestling entrepreneurs Vince and Linda McMahon, and, in fact, has named Linda McMahon to head up the Small Business Administration. 

So it’s no wonder that Trump used the old union word, “solidarity,” in his inaugural address—a first for a president.  Continuing in that solidaristic theme, he added, referring to the American people: 

We are one nation–and their pain is our pain. Their dreams are our dreams, and their success will be our success.  We share one heart, one home, and one glorious destiny.

In fact, in the speech, Trump used the word “we” 45 times and the word “I” just three times.  And according to a Wall Street Journal text-analysis, Trump actually devoted more attention to the theme of equality than had Barack Obama in either of his inaugurals—even if, to be sure, Trump applies the word differently from his predecessor.  (And of course, Trump also used the words “America” and “American” more than any other president.) 

In the meantime, other Republicans, too, are joining this new solidaristic spirit.   And yes, perhaps they have also noticed that Trump won last year by rejecting libertarianism. Indeed, according to political scientist Lee Drutman, the national percentage of hardcore go-it-aloners is somewhere between four and six. 

So the thinking of Middle America is starting to come into focus.  It’s possible for most Americans to dislike Obamacare because it imposes an unfair burden on low-income workers and employers, and because it funds both abortion and sex-change operations—as well as illegal aliens—even as it preoccupies itself with micro-managing the decisions of patients and doctors.  

And yet at the same time, most Americans do like the idea of helping young people get health insurance, and of preventing insurance companies from denying coverage to those with pre-existing conditions.  The polls show that ordinary people embrace those provisions by ratios of 2:1 or more.  

Indeed, no less than Trump himself declared on January 15 that in his forthcoming plan, he wants to see  “insurance for everybody.” 

In that spirit, Sen. Lamar Alexander (R-Tenn.), the chairman of the mighty Senate Health, Education, Labor and Pensions Committee, has been vocal on one salient point: The repeal of Obamacare must be accompanied by the replacement of Obamacare; that is, by a better Trumpcare.  As Alexander said on January 18, while he and his panel heard the testimony of Tom Price, slated to be Trump’s new Secretary of Health and Human Services:

Obamacare should be finally repealed only when there are concrete practical reforms in place to give Americans access to truly affordable health care. 

Alexander added, “It’s not about developing a quick fix.” That is, it’s about getting the new health-insurance policy right.  Repeal and replace.   And on January 26, Alexander reiterated his prudential approach, saying:

Step by step, we will build better systems that give Americans access to truly affordable health care.  We will do this by moving health care decisions out of Washington, D.C., and back to states and patients.

We can observe that Alexander is closely reflecting the views of the folks back home in Tennessee: Yes, they voted for Trump, and their elected officials almost unanimously opposed Obamacare.  And yet at the same time, Tennesseans, overall, are not rich—they rank 45th in the nation, just two places above neighboring Kentucky.  Indeed, median income in the Volunteer State is more than 15 percent below the national median.  

We can thus observe: People of modest means tend not to be libertarians; they are usually willing to work hard, but life has taught them that they occasionally need protection to keep the wolf away from the door.  

To put that point another way, they don’t wish to take a leap into the dark when it comes to their health and the health of loved ones.  Yes, the people of Tennessee like their freedom and independence, but they also know that their freedom, as well as health, can be jeopardized, too, by arrogant and unfeeling private health insurers. 

The idea that careful provision needs to be made for all Americans is not a controversial position among leading Republicans.  Yes, sometimes there’s “noise” over precise word-choices, such as “access” vs. “coverage”—and, of course, the Main Stream Media is always looking for ways to wedge Republicans apart—but to the fair-minded, the underlying unity of most GOPers is self-evident.  For example, on January 18, then-Vice President-elect Mike Pence said on Fox News, “[Trump] has made it clear in the last few weeks that he wants to do ‘repeal and replace’ concurrently.”

On January 22, House Majority Leader Rep. Kevin McCarthy (R-CA) echoed that point, saying, “We are going to repeal Obamacare and replace it”:

We will assure everybody we are replacing it, just as we’ve always said and just like we’ve had the ideas out there that will allow people to actually have a better relationship with their doctor, not have “one size fits all,” bring more choice into the process  . . . and bring the premiums down . . .  People are going to like what they see.

In addition, as the country waits to see what Trumpcare will look like, other  Republicans in the Senate have taken steps toward outlining alternatives to the existing program.  We might observe that they are doing so in a manner that’s in keeping with the GOP’s emphasis on federalism—that is, pushing maximum decision-making down from the federal level to the state level.  

To that end, four Republicans—Sens. Shelley Moore Capito, Bill Cassidy, Susan Collins, and Johnny Isakson—have introduced the Patient Freedom Act of 2017, which would allow individual states to decide for themselves whether or not to keep, gulp, Obamacare. 

Some might ask: Is the proposal of those four senators too much of a concession to the status quo for most Republicans to swallow?  Will some ideological activists accuse the senatorial quartet of being RINOs?  Perhaps they will.  And yet those four lawmakers were duly elected to represent their respective states; we can further note that all of them—Georgia, Louisiana, Maine, and West Virginia–have incomes below the national median.

That is, folks there may need help, even support, in navigating the health-insurance market—and their elected officials know it.

Indeed, another Republican senator, Steve Daines of Montana, has said that he wants to see Medicaid protected as well.  About 236,000 people–a quarter of the population—in his state are on Medicaid.  And that figure, we might note, has increased about 60 percent in the last four years, mostly because of Obamacare.  And so if Obamacare were to be repealed and not replaced, it’s likely that most, if  not all, of those new enrollees would lose their benefits.  So we can ask: Would Daines, eyeing re-election, be happy about that prospect?  Would he vote to cut so many of his own constituents?  Evidently, his answer is “no.” Not everyone will be happy with Daines’ position, but that’s the hard reality of representative politics.   Perhaps the issue can be finessed somehow, as with block-granting of Medicaid, but it will be a struggle—one of many.   As they say, politics is that the slow boring of hard boards.  And yes, in case you’re wondering, Montana, too, is below the national median income.  

On the other hand, if the reader is curious as to which states are above the median, here’s the full list—most of them are represented by Democrats.  And so again we see the reality of the new partisan inversion. 

In any case, since Republicans control the Senate by just a slim 52:48 margin, Trump and Senate Majority Leader McConnell (as we have seen, Kentucky is relatively poor as well), will have to use caution as they seek to shepherd the Trumpcare replacement model through Congress. 

And when that legislation is shepherded, hopefully to a successful completion, here’s a prediction: It will be Trumpian.  That is, it will be cast in the new populist-nationalist model of Donald Trump.  

Yes, if done right, Trumpcare will be the sort of legislation that red-state voters—including the newest Republican voters—will feel good about.  And hopefully, other Americans, too, will see its basic intelligence and decency, even if they might still choose to oppose it.  

It’s with that inclusive spirit that the new Republican majority has been made, and it’s in that spirit that it will be maintained.


Please let us know if you're having issues with commenting.