SALT LAKE CITY -- From the moment the Patient Protection and Affordable Care Act passed in 2010, most elected officials in the sturdily Republican state of Utah have been eager to squash it.
But despite deep uncertainty about the law's future, Utah recorded one of the biggest increases of any state in residents who signed up for coverage under the act this year. The state is seeing a burst of activism against repealing the law -- including from Republicans.
"I'm naturally a really quiet person, but if I sit and do nothing and they take it away, how can I live with that?" asked Kim Nelson, 54, a Republican second-grade teacher who buys coverage through the Patient Protection and Affordable Care Act marketplace and was recently treated for breast cancer. She said she has been calling and writing her congressman.
Many Utah residents still detest the law, but the activity here, and in other politically conservative states, highlights the challenges Republicans and the White House face as they struggle to come up with a replacement.
When Rep. Chris Stewart spoke with constituents by videoconference Wednesday, a woman, who said she had gotten insurance for the first time in her life through the law, asked, "Poor people need it and you're against it -- why?" Congressional offices have been bombarded with calls, emails and social media messages, including from some constituents who had never been moved to contact them before.
"Certainly this is something that's unusual in Utah," said Jason Stevenson, education and communications director at the Utah Health Policy Project, a research group that has a federal grant to help people enroll in marketplace coverage. He said he had noticed a change in attitudes and energy.
Concerned House and Senate aides have reached out to Stevenson's group in recent weeks, he said, to request meetings and detailed information about enrollment trends and how various Republican proposals, like high-risk pools for people with pre-existing medical conditions, would work. In the past, he added, "we really had to push" to get their attention.
"I would say the phone calls are rattling them," he said.
Many customers of the insurance exchanges in Utah are young, middle-class families who rely on marketplace plans because they are self-employed or students, or they cannot afford the coverage offered through their jobs, Stevenson said.
Other marketplace customers, like Nelson, took jobs that do not offer health insurance because they could get coverage through the Affordable Care Act.
Nelson said the option had allowed her to work at a job she loved, at a small private school. She has called and written Rep. Mia Love, the Republican who represents her district, because she is afraid she will have to change jobs if the law is repealed.
Many Utah voters were uncomfortable with President Donald Trump's candidacy, though he still won the state with 45 percent of the vote compared with 27 percent for Hillary Clinton and 21 percent for Evan McMullin, a conservative Mormon who ran as an independent.
Mary Wood, a divorced mother of two who works three part-time jobs, none of which offers health insurance, said she had voted for McMullin as part of "this movement in Utah of people who had a hard time completely putting themselves behind either Trump or Hillary." But now, she said, with Trump pushing for a repeal of the health law and for other policies she opposes, her vote is "one of the biggest regrets of my life."
She pays $75 per month for a plan that covers her family of three, receives a subsidy of $558 and worries about the type of replacement that was laid out in a draft bill recently published by Politico. That plan would provide age-based tax credits that would be most generous for older people; Wood, 39, fears it would provide her with far less financial assistance than the income-based subsidies she gets through the Affordable Care Act.
"I tried to call Orrin Hatch, and his voicemail box was full," she said. "I would have told him, 'Look, this is going to personally affect me and my children if you repeal the ACA.'"
In a statement, Hatch said the law was "imploding from within," adding, "I've spoken to Utahns from all over the state and from all walks of life, and the vast majority favor our efforts to repeal and replace Obamacare with patient-centered reforms that lower costs."
As in all 19 of the states that have not expanded Medicaid, tens of thousands of people in Utah are stuck in a coverage gap, eligible for neither Medicaid nor premium assistance under the law. Many still rely on charity care offered by places such as the Volunteer Care Clinic, a busy, free clinic run by doctors and nurses in Provo two nights a week.
Even the most conservative parts of the state have residents who have benefited from the law or know someone who has. When The New York Times asked Utah readers to share their experiences, hundreds who filled out the online questionnaire said they wanted the law to survive. Many came from Republican strongholds like Utah County, home of Provo, where only 14 percent of voters backed Clinton last fall.
A healthy minority of respondents said they opposed the law and wanted it repealed, usually citing high costs and few choices for coverage. Three insurers are participating in the Utah marketplace this year, but most counties have only one. Premiums for midlevel plans rose by 20 percent on average this year in Utah, with higher increases in rural areas, but about 85 percent of marketplace customers qualify for subsidies to help with the cost, often substantially.
Enrollment grew by 12.3 percent to 197,187 this year in Utah, a time when nationwide enrollment dipped slightly, according to preliminary federal data. And the gains were not concentrated in left-leaning parts of the state: Utah County, where nearly 60 percent of voters are Republican, experienced a 26.7 percent enrollment increase through the end of December, Stevenson said, while Salt Lake County's enrollment grew by only 2.3 percent.
A Section on 03/05/2017