Where should Democrats head after their recent electoral rout? As it happens, coming fights about federally subsidized health insurance offer the party a golden opportunity to engage people far beyond its urban strongholds, in communities that will be hard hit by Republican plans to shrink Medicaid, privatize Medicare and eliminate the taxes that pay for Obamacare subsidies.
Donald J. Trump won the Electoral College, and Republicans maintained congressional majorities, because of overwhelming victories in small cities, outer suburbs and rural counties. Yet the president-elect and the Republicans are poised to deliver blows to the social fabric and economic underpinnings of those very communities. Along with Representative Tom Price, Mr. Trump’s nominee for secretary of health and human services, congressional Republicans say they want to move quickly to revolutionize all types of federal health insurance spending, using special procedures that require only 51 votes in the Senate.
Congress will be asked not only to cut the taxes levied on businesses and the rich to finance Obamacare benefits for 20 to 30 million low and middle-income Americans; Republican leaders also plan to slash federal commitments to Medicaid, giving states the authority to shrink this health care program for the poor and elderly. And Republican House members, led by Speaker Paul D. Ryan, seem determined to abolish traditional Medicare insurance for retirees and replace it with “premium vouchers” that would throw older Americans on the mercies of private insurance markets and require them to pay more for their care.
Trump voters will be especially hard hit if just part of this sweeping agenda comes to fruition.
Conservatives often point to poor blacks and Latinos as the primary beneficiaries of federal health insurance programs. But such rhetoric obscures the enormous importance of Medicaid, Medicare and Obamacare subsidies to economically struggling white Americans living in small cities and rural areas. In Pennsylvania, where Mr. Trump narrowly beat Hillary Clinton with overwhelming support outside big cities, about 17 percent of residents are 65 or older, above the national average. Meanwhile, some 16 percent of Pennsylvanians benefit from Medicare, and 18 percent from Medicaid. With the bulk of Medicaid going to elderly and disabled residents, that program is the single largest federal subsidy flowing into the Keystone State.
Repealing the Affordable Care Act would also hit Pennsylvania hard. Under the act, some 468,000 low-income Pennsylvanians had gained Medicaid coverage by August 2016, and another 439,000 bought private coverage on the Obamacare marketplace, with more than three-fourths of those people getting tax credits averaging $251 per month. Health care is often sparse in nonurban areas, and the providers that do exist depend on federal insurance programs that help many patients pay for care. If radical Republican cutbacks in federal contributions to health insurance are enacted, Pennsylvania hospitals and health care businesses will lose vital revenues, leaving many lower-income and sick Pennsylvanians at risk of losing access to care.
This is the case in other states as well, meaning many rural and small-town Trump supporters may soon see that Make America Great Again means accelerating economic decline and social devastation. Mr. Trump shows little understanding of the intricate interplay of subsidies and rules in the health care system, and probably has no inkling that federal taxes collected from liberal states like California, Massachusetts and New York heavily subsidize vital health services, businesses and family benefits in the very places that voted heavily for him. In delegating plans for huge health care cutbacks to hard-right congressional Republicans, he will be hurting his own base.