Ever since Donald Trump’s shocking victory on Election Day, press, pundits, and pollsters have engaged in a furious debate about which voters propelled him to the White House. Was Trump’s win the revenge of the “guns and bitter crowd” in the Rust Belt, the white working-class voters whose racism, xenophobia and/or “economic anxiety” led them to pull the lever in 2016 for the reality TV star? Or was the Republican’s core support throughout the primaries and the general election made up of more affluent and suburban backers? And as Trump’s approval ratings continue to spiral downward to levels not seen since George W. Bush ambled out of the Oval Office, can he continue to count on an unshakeable “floor” of 35 to 40 percent support?
While these are all interesting questions, one thing is certain. Donald Trump, like Republicans nationwide over the past decade, has enjoyed the steadfast support of older voters. Since 2008, Americans (especially white Americans) over the age of 50 have reliably rallied behind GOP candidates. But under the American Health Care Act (AHCA) Majority Leader Mitch McConnell is now trying to sneak through the Senate, it will be the gray and the graying who suffer the most.
To fully measure the magnitude of the coming Republican betrayal of older voters with the AHCA (a.k.a. Trumpcare), it helps to first appreciate their recent loyalty to the GOP. As the charts of exit poll data since 2008 above show, Americans over age 50 show up to vote and vote for Republicans. During presidential election years, voters ages 50 to 64 and over 64 combined have represented between 42 and 46 percent of the electorate. But in the 2010 and 2014 midterm balloting, their share reached a staggering 53 and 55 percent. While John McCain narrowly lost 50- to 64-year-olds by one point in 2008, Mitt Romney and Donald Trump had no difficulty winning voters over age 50 in 2012 and 2016.
The American Health Care Act is their reward for their loyalty. It’s a loyalty expected by the GOP and (as we’ve learned) demanded by Donald Trump.
As I recently summed up the bill passed by the House in May:
Three weeks after House Republicans voted to pass a new version of their “American Health Care Act,” the nonpartisan Congressional Budget Office (CBO) weighed in on high-profile pledges from President Donald Trump and House Speaker Paul Ryan. While Trump guaranteed “insurance for everybody” that is “much less expensive and much better,” Ryan insisted the revised AHCA “protects people with pre-existing conditions.” Not content to rest there, HHS Secretary Tom Price boasted that Trumpcare’s $880 billion in cuts to Medicaid will "absolutely not" result in millions losing coverage.
As it turned out, under the leadership of the GOP’s hand-picked boss Keith Hall, the CBO demolished every one of the Republican leadership’s lies:
The CBO numbers are scary for Republicans and horrifying for the American people. Version 3.0 of the AHCA would leave 23 million people uninsured by 2027, and 14 million dropped from the Medicaid rolls. AHCA 3.0 would save only $119 billion, compared to $337 billion forecast during the House’s first go-around in mid-March. And with its MacArthur amendment allowing states to obtain waivers to avoid Obamacare’s mandatory dozen “essential health benefits” (EHB’s), the American Health Care Act would jeopardize insurance coverage for those with pre-existing conditions.
Faced with the difficult task of guessing which states would and would not take advantage of those EHB waivers, CBO assumed one-half would not, about one-third would end some of those patient protections, and one-sixth would waive them altogether. With its aged-based tax credits that rise only using an inflation formula (and not increases in premiums as Obamacare does), the AHCA would hurt older, sicker Americans. While premiums rise at first, they would decline starting in 2020 as those over age 50 are increasingly priced out of the market altogether.
It's no mystery as to why. Under the community-rating in Obamacare (a.k.a. the Affordable Care Act), insurers cannot charge older Americans more than three times what they do for 18 to 29-year-olds. But under the AHCA, that ratio jumps to 5 to 1, ensuring higher premiums for the graying and the gray. Because Trumpcare’s subsidies to purchase insurance are based on age and not income, premium payments will rise dramatically. These will only worsen over time, as the AHCA’s tax credits increase only by an inflation-based formula, and not with rising premiums from insurers. Trumpcare’s elimination of cost-sharing reductions (CSR’s) exacerbates the problem, as households earning less than 250 percent of the federal poverty level will lose the help they get today with deductibles and out-of-pocket costs. Adding insult to injury, older Americans are much more likely to already be sick or injured. While 27 percent of non-elderly adults suffer from pre-existing conditions, according to the Kaiser Family Foundation that figure is one-third for those ages 50 to 54, and nearly half of those 60 to 64 years old.
As the Wall Street Journal reported, “Top 10 States for Pre-Existing Conditions All Went for Trump.”
The result, KFF warns, is that 5 million people ages 50 to 64 will lose their health insurance if the House version of the American Health Care Act becomes law:
As the CBO forecast, the percentage of uninsured between ages 50 and 64 would more than double.
As many have noted, the GOP’s plan to “repeal and replace” Obamacare will hit Trump voters hardest. It’s no mystery as to why. As the New York Times explained, “The Republican plan offers less assistance to older and lower income Americans, especially in rural areas.” Due to the lack of competition for insurers and health care providers, as the Center on Budget and Policy Priorities (CBPP) documented, 12 of the 15 states hardest hit by the AHCA’s shriveled tax credits are rural ones. Fourteen of the 15 voted for Donald Trump for president in 2016. And with the GOP’s plan to redirect $880 billion in Medicaid spending to tax cuts for the richest Americans, older Americans—especially those near the poverty line—will face catastrophic increases in premiums, rendering health insurance an impossible acquisition:
(It should be noted that these effects won’t be limited to those obtaining insurance through the individual or non-group market. As the Wall Street Journal (“GOP Health Bill Jeopardizes Out-of-Pocket Caps in Employer Plans”) and the Brookings Institution warned, “Allowing states to define ‘essential health benefits’ could weaken ACA protections against catastrophic costs for people with employer coverage nationwide.”)
Now, it should be said that the version of the AHCA Senate Republicans are contemplating may not be as disastrous as the draconian House bill. It is rumored that the phase-out of the Medicaid expansion may be extended to seven years. While maintaining the ability for states to waive Obamacare’s list of essential health benefits, a Senate bill may limit insurers ability to charge more to those with pre-existing conditions who let their coverage lapse. Regardless, Senate Majority Leader Mitch McConnell is committed to getting a vote on the GOP’s Obamacare replacement bill before the August recess. As for Donald Trump, he’s “all in.”
Trump may be all in, but the question remains whether he is in trouble with his voters when it comes to health care. After all, a Kaiser poll last week found that only 8 percent of respondents support the American Health Care Act “as is.” Just as dangerous for the president and his Republican allies bent on sabotaging Obamacare, Americans by a 2 to 1 margin say it will be Trump and the GOP’s fault if it fails. Whether that disappointment turns into disgust and disowning Trump is a different matter altogether.
That paradox is what Sarah Kliff of Vox found when she traveled to Kentucky to talk to Trump voters who were also Obamacare enrollees. From the beginning, Kentucky has been an Obamacare success story, reducing its uninsured rate from more than 20 percent to just 7.8 percent today. But as they learn more about Trumpcare, the over-50 voters Kliff spoke to were turned off by—but not ready to turn on—Donald Trump and the GOP.
“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.”
Kathy Oller, an Obamacare enrollment worker who also voted for Trump in 2016, knows the impact the new president will have and is already having:
“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.”
Bob Hoskins, 62, isn’t as sure. The former coal miner suffering from black lung disease, kidney issues, and depression said Obamacare brought him “the best insurance I ever had in my life.” But Trumpcare would drastically change his standard of living:
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.
That, Hoskins said, would put him “back in poverty.” And it might just put him among the ranks of Kentucky Democratic voters. But, as Kliff concluded, he probably wouldn’t have much company. “Like my dad told me, this is a Republican county.”
But eastern Kentucky isn’t representative of the whole state and certainly not of the whole country. (Trump carried Kentucky by 63 to 33 percent.) And the damage that the American Health Care Act will do to those GOP voters in the 50- to 64-year-old age group hasn’t happened yet. But if Trumpcare becomes the law of the land, the damage will be severe—and just beginning. After all, while the elderly are just 10 percent of Medicaid’s recipients, Americans over the age of 65 account for 23 percent of its budget for nursing care and other programs. And Donald Trump didn’t just promise to protect Medicaid, he repeatedly pledged no cuts to Medicare, too. But privatizing and rationing Medicare isn’t just a plank in the 2016 Republican platform. House Speaker Paul Ryan has been pursuing it for years.
Of course, you’d never know any of this from Republican rhetoric targeting voters with gray beards or blue hair. Republicans swept to an overwhelming victory in the 2010 midterms by falsely claiming that Democrats were “sticking it to seniors” with a $700 billion “raid on Medicare” to fund Obamacare. It worked, but it wasn’t true. The ACA was funded in part by savings from private Medicare Advantage insurers and payments to Medicare providers. But every Republican budget has kept those same savings. The American Health Care Act is no different. That’s why Paul Ryan stopped tweeting about “Obamacare raided and rationed Medicare to the tune of $800 billion.” And that’s why former RNC Chairman and current Trump chief-of-staff Reince Priebus doesn’t regurgitate smears against President Obama like this one anymore:
“He stole $700 billion from Medicare to fund ObamaCare. If any person in this entire debate has blood on their hands in regard to Medicare, it's Barack Obama.”
Now, the shoe is on the other foot. And if the GOP Congress passes and Donald Trump signs the American Health Care Act, the blood will be on Republicans’ hands. And that red blood will have been drawn from those most reliably red voters—the ones with the gray hair.
Full disclosure: I’m 55 with mostly gray hair and an increasingly gray beard. The Republicans’ planned health care body count is yet another reason why I vote blue.
UPDATE: After overwhelming feedback from commenters, the original chart deemed confusing at the beginning of this diary has been replaced. Instead, two separate charts respectively now show the GOP share of voters over 50 and the share voters over 50 as a percentage of total turnout.