Amidst messaging wars on Capitol Hill about the Affordable Care Act, voters say they are most concerned with the economy and remaining employed.
But in addition to a loss of health coverage for as many as 30 million people, a repeal of the ACA could mean 3 million fewer jobs and significant revenue losses for providers. So, while the label "Obamacare" may be unsalvageable, Democrats could re-brand healthcare reform.
On Capitol Hill this week, political leaders warned their parties that what lies ahead will include a public relations struggle where both sides are intent on blaming the other for whatever negative news follows congressional action.
Senate Minority Leader Chuck Schumer (D-N.Y.) is riffing on President elect Donald Trump's campaign slogan by saying Republicans will “make America sick again.”
“They want to repeal (the ACA) and then try to hang it on us. Not gonna happen,” he told reporters. “It's their responsibility, plain and simple.”
Meanwhile Trump was tweeting that “Republicans must be careful in that the Dems own the failed ObamaCare disaster.”
But Drew Altman, president and CEO of the Kaiser Family Foundation, said recent research shows that people like many aspects of the ACA, even as they may rail against “Obamacare.”
“Very much unlike policy makers in Washington, they're not committed to any particular policy direction or ideological framework. They just want some help,” he said.
A KFF poll released Friday shows that economy and jobs was the top overall concern and the main issue for Democrats and Independents. Healthcare was third overall and second for Democrats and Independents.
It's not entirely clear what survey respondents mean when they refer to the economy and jobs, but Altman says it is more about a general sense of personal economic security and being able to afford gas and groceries rather than monthly jobs reports.
Republicans have been keen to label the ACA as a “jobs killer,” but evidence doesn't support that. A new study shows that repealing it, however, might be.
ACA repeal could lead to 2.6 million jobs lost in 2019 and as many as 3 million by 2021, according to the study by the Milken Institute School of Public Health at the George Washington University and The Commonwealth Fund.
It focuses on the effects of repeal of Medicaid expansion in states and the loss of premium tax credits to help people buy coverage on individual insurance exchanges.
One-third of the job losses would be in healthcare but the rest would be in a variety of other industries.
Leighton Ku, a professor at George Washington University who worked on the paper, said repercussions from appeal would happen quickly because states would lose federal funding and more uninsured residents would visit public clinics.
Republican Michigan Gov. Rick Snyder has been outspoken about the benefits his state has seen from the ACA's Medicaid expansion. More than 30,000 jobs and $2.3 billion in economic benefits accrued to Michigan since expansion, according to a new study by the University of Michigan's Institute for Healthcare Policy and Innovation.
Other economists say the ACA's impact has been modest and on balance.
“The effects might go in either direction,” said Gary Burtless, a fellow at the Brookings Institution.
But providers are steeling themselves for rough waters ahead.
The Affordable Care Act created healthcare jobs because as more people got insurance, demand for care increased. At the same time, more care was being reimbursed either through private payers or federal programs. That gave hospitals more revenue to spend on personnel.
The Urban Institute found that if the ACA is repealed, insurer and household spending on hospitals would decrease by $59.1 billion. The newly uninsured would cost an additional $24.6 billion in uncompensated care from hospitals in just 2019.
There are difficulties in touting those jobs as a political achievement, though. For one, more jobs in the healthcare sector can mean less success in controlling overall healthcare costs. Also, the jobs that are created tend to be higher skilled.
Ani Turner, co-director of the Center for Sustainable Health Spending at the Altarum Institute, said low-income people desperately seeking employment aren't as likely to find a job in the sector, even if hiring is expanding because they aren't qualified for the positions.
And while researchers have found correlations between the ACA and job growth, as well as other data that leads them to believe there is a connection, it's hard to definitively prove.
“Correlation with expansion and timing makes sense, but it's not really proving anything to someone who doesn't want to believe it,” Turner said.
As Republicans realize the drastic effects that would come from repealing the ACA without anything in place to come after it, they have been backtracking on previous statements. Some lawmakers have said there could be a years-long transition or that certain provisions and taxes could stay in place.
The KFF poll found that 67% of people said lowering the amount individuals pay for healthcare was a top priority. Only 37% said repealing the ACA was a top priority.
But Vice President elect Mike Pence told reporters after meeting with GOP lawmakers on Capitol Hill Wednesday that the GOP would keep it's promise during the elections. "We're going to repeal Obamacare and replace it with solutions that lower the cost of health insurance without growing the size of government."
The ball is now in their court, Altman said. "My view is that the Pottery Barn rule will apply and if you break it you own it,” he said. “And if Republicans control both the Congress and the White House, they will own it.”