“Repeal and replace” has been the rallying cry for opponents of the Affordable Care Act (ACA or Obamacare), the signature domestic policy of the Obama administration that expanded insurance coverage to 20 million people. Opposition to the ACA inspired populist social movements and helped elect Republicans to state and national office. Donald Trump tweeted hundreds of times that Obamacare was a “disaster” and promised to repeal and replace the health law. And yet, since he took office in 2017, public opinion polling shows that more Americans hold favorable views than unfavorable views of the law, reversing previous trends. Constituents have confronted members of Congress at rowdy town hall meetings and demanded that their health coverage be protected. Bewildered Republicans and health policy wonks are scratching their heads, trying to make sense of the sudden surge in support for what has been an unpopular law. Finally ready to make good on their campaign promises to repeal and replace, Republicans are met by desperate Americans, many with preexisting conditions, who fear their coverage will soon disappear.
Here, we explore this pendulum shift in public opinion poll results about the popularity of the ACA. We argue that, in fact, many pollsters and policy wonks never really understood the complicated assessments that people held of the ACA in the first place. A question about favorable or unfavorable views fails to capture the stakes of the ACA for those with and without health insurance. Poll data show that major reasons for disliking the health reform included increased costs, that it created too big a role for government, that it took the country in the “wrong direction” under President Obama, and that it did not go far enough in expanding coverage. Of course, in such polls respondents must choose among preselected options rather than being able to express their opinions in their own words. In addition, the way the results are aggregated and displayed erases the fact that many people hold multiple, overlapping, and often contradictory views simultaneously.
Based on ethnographic research with the newly and still uninsured in our forthcoming book Unequal Coverage: The Experience of Health Reform in the United Status, we found that when people criticized Obamacare, they did it for many different reasons that rarely issued from a cohesive ideological position. In addition to affordability and anti-Obama sentiments, our ethnographic research has also shown that people were dissatisfied because they felt left out of the law or felt that “others” (besides themselves) were benefiting more from the law. We also heard that deductibles were too high; that people experienced bureaucratic hurdles to enrollment; that not all doctors would accept the coverage; disagreement with the tax implications of the law; and that the website was too difficult to navigate. While some of these reasons are ideological, many of them are related to bureaucracy, price, the design of the law, and the issues with implementation. Furthermore, only a small minority of people in the United States (6%) ever actually got their health coverage through the ACA (20 million in 2016 out of a population of roughly 325 million).
As the contributors to this anthropological volume argue, the law became a flashpoint for battles over inequality, fairness, and the role of government. It also became a vehicle for generating and fanning resentment. Because the law was so overwhelmingly complex and access to health care is such a life and death issue; it evoked strong emotional reactions. Skillful politicians tapped into these emotions by bashing unpopular aspects of the law while still holding out the possibility that something better was possible (though that something was never well defined). Rather than dismissing Trump supporters as ignorant or self-destructive, as many liberal news outlets have done, we hold that critics of the ACA are just as rational, complex, and flawed as people anywhere and that if we want to know what motivates them and how they think about the world, we should probably talk to them.
We agree with anthropologist Jessica Smith that the media coverage of Trump voters was a “spectacle—one that entertained liberals by constructing an impossibly idiotic, illiberal rural electorate.” In the aftermath of the election, Trump voters have been cast as monolithic and blindly accepting of his entire project. Anthropologists would not tolerate this kind of caricaturing and lack of nuance in representations of most other peoples, but our discipline has often lagged behind in understanding interior others, like poor whites and rural residents in the United States. It is critical to understand that many white and working class rural voters are both exploited, insecure, and passed over by a changing economy and eager to latch on to narratives of racial resentment that exploited others in order to feel more secure. Furthermore, many people of color, especially in the south, were also left out of the law, some by design and others by the law’s uneven implementation. They too, have important critiques of health reform that defy simple ideological classification.
To illustrate some of the complexity in how individuals made sense of the ACA, take the case of Trina. She lives in a rural county in Florida, has a high school education, and has worked in service jobs for most of her adult life, only rarely having employer-sponsored coverage. At age 55, Trina earns $26,000 a year from her food service job at a long-term care facility. She also supports her husband, who is not currently working. Trina hadn’t had a full physical in about ten years. She mostly goes to the doctor when she has a cold that won’t go away and develops into something like bronchitis. Working with elderly patients, she doesn’t want to get anyone else sick or risk catching something from them.
Trina’s employer offers health coverage, but it is too expensive. So, when Trina heard about Obamacare plans from some of her co-workers, she got more information from a Blue Cross Blue Shield insurance broker and signed up. In 2016, she and her husband qualified for significant tax credits—their premium was $42 a month with no deductible. Despite this relatively affordable price, the family was living paycheck-to-paycheck, so that the smallest setback made insurance unaffordable. They ran into some financial problems in May of 2016 and stopped paying their premiums, so their coverage lapsed. “I could kick myself,” Trina said recounting how good her coverage was.
Trina and her husband were uninsured at the beginning of 2017 and didn’t anticipate gaining coverage again anytime soon. When she tried to sign up again in 2017, the premium for the same plan was $200 a month and her deductible was $6000. She was still getting help directly from a BCBS representative, so she might have qualified for more affordable coverage from other carriers and just not known it.
Her main concern, though, was not paying the tax penalty: “You know, now it’s up to $600 this year and that’s per person,” she said. “I don’t even think I’ll make that in income tax. So, that means that I’m going to be owing for something that I can’t afford to begin with, it’s like Catch-22.”
But then she went on to say that she was not mad that the government wanted her to have insurance: “I don’t mind the government telling me I have to have it, but you know all these prices have gone up and now you are saying you have to have it and if you don’t we’re going to fine you. You are between a rock and a hard place.”
Trina was critical of the individual mandate, not because it was an example of government overreach, but because there was no way that she could stay covered, receive a full income tax return, and continue to keep a roof over her head. It asked too much of her already strained finances to also buy health insurance when she was not accustomed to regularly using medical care and thought of herself as healthy. “Yes, I know someday I’m going to get sick and I’m not going to be able to gargle with salt water and make it go away, but you know that’s a risk—you know right now in order to keep a roof over my head. Electricity on, and stuff. I got to eat too.” Paying for insurance or eating, this was the choice that Trina faced.
So, when asked if she was optimistic or pessimistic after the election, she said she was optimistic. “I’m hoping it gets better. I’m feeling positive, so I know we are going for the better.” She was a Trump supporter and though she didn’t think she would gain access to affordable insurance coverage anytime soon, she did think that he would be able to get rid of the individual mandate and then at least she would have a little bit of extra money in her pocket.
At the end of the interview, Trina said she would like to see the U.S adopt a health care system like they have in Canada: “Healthcare available to all. I realize that’s going to raise the prices of other things, but your health is protected.”
What would a poll would have told us about Trina’s assessment of the Affordable Care Act? Ethnographic interviewing shows that she has a complex, multifaceted, and rational position. She is against the ACA to the extent that the coverage was not affordable and she was penalized for being uninsured when she felt she couldn’t really afford the coverage. She is a Trump supporter, but not wildly against Obamacare. Her views were strongly shaped by her economic location and the real trade-offs she must make to cover her basic needs. She saw health insurance as a luxury just out of her reach. Nonetheless, she desired greater access to care for everyone and was willing to pay more for other things to have it. Trina, a Trump supporter, was actually in favor of a single-payer system similar to Canada’s. The static and binary representation of opinion that political poling relies upon wouldn’t tell us much about how Trina understands health care.
Of course, Trina doesn’t represent everyone’s views. In the book we draw on hundreds of interviews to tease out the complicated assessments of the ACA held by those the law was supposed to help. This includes people who were excited to be covered for the first time and attended outreach events or utilized the website, only to find out they did not fit the criteria for Marketplace assistance and fell within the coverage gap.
Carlos is a 45-year old married father of two, who lives in a South Texas border county where almost one in three persons remain without health insurance, even after the ACA. On a Saturday morning, he and his family attended a health insurance outreach event at a local community health center, complete with games for the kids and a raffle to attract people from the surrounding community. After waiting in line to speak with an enrollment specialist, he discovered that he earns too little to qualify for insurance subsidies. He was confused by this, since he assumed the subsidy was designed for those who need a little assistance. What remained unstated was that Republicans in Texas had just blocked Medicaid for poor and working adults in their state. In another state, he and his wife would have obtained coverage that Saturday morning.
Despite a strong desire for health care coverage – and a willingness to pay for the opportunity – Carlos is one of the many who have been excluded by design. They have been effectively shut out, due solely to the state in which they live. Texas is one of 19 states that has remained in opposition to the ACA, with state lawmakers rejecting the Medicaid expansion and leaving millions of low-income working adults without a coverage option. These individuals became caught in the “coverage gap,” in which their incomes exceeded their states’ Medicaid eligibility criteria but were too low to qualify them for subsidies to assist in purchasing insurance through the exchanges. As a result, a large portion of the population in some states has remained unaffected by the progress made through the ACA, because they were among the working poor making less than 100% of the federal poverty level. For people like Carlos, the ACA both reinforced existing and produced new forms of regional, economic, and ethnic inequality.
The examples of Trina and Carlos show how necessary a grounded approach to understanding policy is, and why anthropologists should be at the table. Assessing simply a favorable or unfavorable view of the law prevents us from learning from the experiences of those the ACA was supposed to help. These are the very people who can provide nuanced evaluations of where the law worked and where it went wrong, if only we were willing to listen. People may not have been happy with every aspect of the ACA (like paying a fine, cumbersome enrollment processes, and coverage that is still too expensive), but they did want health coverage and most people do seem to think that the government needs to play a role in making that possible (despite what ideologues on the Right say and despite the far more limited role for government in the AHCA).
Had we been listening all along to how the ACA was impacting people’s lives, we might have been less surprised when attacking the law bolstered Trump’s appeal. In our ethnographic work we’ve learned at least three things about how people make sense of and evaluate the ACA. First, favorable or unfavorable isn’t nearly nuanced enough of a frame for understanding the Affordable Care Act’s achievements and failures. The people we spoke to had complex assessments and pointed to things they liked about the law as well as the areas in which it fell short. Second, we need to set aside simplistic narratives about critics of the ACA, such as that it is simply a racist reaction to President Obama or that rural people are too ignorant to understand that the law actually helps them. The ACA was a complex law that impacted people’s lives in contradictory ways. Third and finally, the law elicited feelings of inclusion and exclusion as many longed for the security of health insurance, yet still found themselves uninsured. As repeal looks more imminent, it makes sense that people’s complex assessments and strong feelings about inclusion and exclusion are bubbling to the surface.
Jessica Mulligan is Associate Professor of Health Policy and Management at Providence College. Her current research explores insurance, financial security, and health reform from the perspective of the newly insured and those who continue to lack coverage. She is co-editor of Unequal Coverage: The Experience of Health Care Reform in the United States (NYU Press, fall 2017). Her first book, Unmanageable Care: An Ethnography of Health Care Privatization in Puerto Rico was published by NYU Press in 2014.
Heide Castañeda is Associate Professor in the Department of Anthropology at the University of South Florida. She received a PhD in Anthropology from the University of Arizona (2007), MPH from the University of Texas (2002), and MA in Anthropology from the University of Texas at San Antonio (2000). Her primary research areas include migrant health, health policy, undocumented/unauthorized migration, and constructs of citizenship.