What kind of health plan do voters want?

An illuminating column in the New York Times this morning shows the dilemma facing legislators intent to repeal and replace the Affordable Care Act.  Drew Altman, CEO of the Kaiser Family Foundation, reported the findings of focus groups of working class Trump voters in Rust Belt states.  All of the participants receive insurance via the ACA, either through private coverage in the marketplace or Medicaid.  There was much dissatisfaction.

The focus group participants were concerned about rising premiums, deductibles, copays, and drug costs.  They thought their policies were too complex and didn't like the idea of shopping around and possibly changing plans every year.  They weren't happy with surprise bills for services they thought were covered.  And those with private insurance resented the better deal they perceived those with Medicaid were getting.

In short, they sounded a lot like health insurance consumers before the ACA.  

When presented with possible "solutions" that have been proposed in GOP replacement plans for the ACA, however, they weren't any happier. Catastrophic coverage with even higher deductibles than they face now were labeled as "not insurance at all."  They did not understand heath savings accounts and were skeptical of the concept.  They were fearful of what would happen if there was a gap between repeal of the law and replacement. 

What do they want?  Low out-of-pocket costs, low drug prices, robust provider networks, no surprise bills, and easy to understand policies.  Again, the same things that everybody wanted before the ACA. 

The problem, of course, is that it's easy for politicians to promise unicorns and rainbows.  In the last six  years, the U.S. House of Representatives voted more than 60 times to repeal the ACA.  During the campaign, President-elect Trump pledged to repeal it and replace it with something "terrific" shortly after taking office.  These promises were easy because they weren't yet real. 

But now that repeal could happen, the spotlight is on replacement.  And not a single politician who has screamed for repeal all these years has any idea how to deliver what the focus group voters say they want.  Because it can't be delivered.

Real policy requires tradeoffs.  You want low out-of-pocket costs?  That means higher premiums.  Broad provider networks?  Again, higher costs.  A smooth transition without a gap between plans?  That could take years. 

Will politicians have the courage to be straight with their constituents and tell them these truths?  Until they do, the comments from the focus groups won't change, whether they're made up of Trump voters, Clinton voters, or anybody else.  Regular people aren't policy wonks.  They rely on their leaders to explain to them how this all works.  Will anybody step up?