Executive Summary

President Donald Trump and Republicans in Congress are moving to follow through on their campaign promise to repeal and replace the Affordable Care Act (ACA). To gain a better understanding of the personal experiences of Trump voters with health coverage provided through the ACA and the changes they hope to see in the health system moving forward, the Kaiser Family Foundation (KFF) held focus groups in December 2016 with Trump voters in cities in three battleground states (Michigan, Ohio, and Pennsylvania), who had coverage through the Marketplaces or through the Medicaid expansion. These Trump voters with personal experience with the ACA are not likely to be representative of people who gained coverage through the ACA generally, nor are they representative of all Trump voters. Following are key themes from the groups:

Perspectives of Trump Voters with Marketplace Coverage

Although some participants reported positive experiences with Marketplace coverage and found it affordable, many were overwhelmed by unaffordable, out-of-pocket costs associated with high deductibles. Participants were also frustrated by surprise medical bills and the high cost of prescription medications.

Improving the affordability of coverage (in terms of premiums and especially out-of-pocket costs) was Marketplace participants’ top priority for an ACA replacement plan. They also wanted access to a broader range of doctors and hospitals, simplification of health plan choices, greater transparency on coverage and costs, elimination of the individual mandate, continuation of ACA coverage of pre-existing conditions, and the ability to tailor coverage to fit their needs (even if sicker people would pay more for coverage).

Participants almost universally rejected the idea of low-premium, high-deductible plans coupled with Health Savings Accounts (HSAs), which are expected to be a key element of Republican replacement plans. They feared that the deductibles would be unaffordable, causing people to avoid seeking needed care, and felt that they would not be able to build up enough savings even with an HSA to cover the out-of-pocket costs associated with a high deductible plan.

Perspectives of Trump Voters Who Gained Coverage under ACA Medicaid Expansion

Medicaid participants faced more serious health issues and greater financial challenges than those in the Marketplace groups. Many suffered from health conditions that impacted their ability to function, and they were grateful for Medicaid coverage that provided them affordable access to needed care and medications.

Although most Medicaid participants did not associate their coverage with the ACA, they were happy with their coverage and were distressed about what would happen to them if their coverage were repealed.

While participants feared losing their coverage, they had mixed views of more minor changes such as charging small premiums to Medicaid enrollees or incentives for healthy behavior. However, given their tenuous financial situations, they were not supportive of lock-out periods for failure to pay the premiums on time.

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