Stop me if you’ve heard this one. A Trump voter in Trump country—maybe a coal miner in West Virginia or the patron of a sleepy diner in rural Kentucky—is a recipient of Medicaid coverage under Obamacare for a life-threatening illness or chronic condition, but still maintains total support for President Trump and a zeal for repealing the program.
Soon enough, there may be an addition to the tale of the anti-Obamacare Trump voter. On Thursday, the American Health Care Act, the Republican plan to repeal and replace Obamacare, passed the House after months of deliberation and frustration for the party. Party leaders celebrated in the Rose Garden; perhaps people in Trump country celebrated, too. But Democrats are likely fretting over the prospects of a bill that many of them deemed politically impossible. How did a bill that almost certainly makes health-care more expensive for low-income, sicker, older, and more rural voters who make up much of the Republican base even make it this far?
One good answer might come from a recent interview on the AHCA between Alabama’s Representative Mo Brooks and CNN’s Jake Tapper. “[The plan] will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool,” Brooks claimed. “That helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. And right now, those are the people—who’ve done things the right way—that are seeing their costs skyrocketing.”
That interview was such a stunner because it’s exactly what Republicans aren’tsupposed to say about their health-care bill. Most Republicans paint their support for the AHCA in terms of the deficiencies of Obamacare, the problems low-income people face obtaining affordable health-care, or a perceived inability of the country to pay for the broad benefits of the program.
When pressed, despite the evidence otherwise, party leaders like Speaker Paul Ryan break out PowerPoint to argue that their plan will actually help low-income people and people with pre-existing conditions. Even provisions that are obviously more rooted in a moral background, like support for work requirements in Medicaid, are painted as pieces that will make the whole law better and benefit the lives of everyone involved.
But while Brooks’s comments stray from Republican talking points, they may help explain both the internal logic of the American Health Care Act and one of the main elements to the political appeal of Trumpism.
The AHCA, even by conservative think-tank calculations, will leave many low-income and sick people without insurance they can afford, and does so even as it makes health-care work better for healthy people. Brooks’s explanation, and his close association of morality and health, with the idea that “good lives” produce good health, is just a recasting of the prosperity gospel.
What’s a religious philosophy mostly pioneered by wealthy televangelists and megachurches got to do with pre-existing conditions and Medicaid reform?
The beliefs of some evangelicals connecting wealth to God’s favor became intertwined with faith healing, and both rose to new heights in the television era on the backs of men like Oral Roberts. While it became part of the cults of personality around the generation of Pat Robertsons and Peter Popoffs that followed Roberts’s lead, faith healing was also undeniably a policy statement. It at least partially rejected the role of science in public health and encouraged a view that faith, virtue, and good works could be enough to secure healing. And although the furthest extremes of the prosperity gospel often bring to mind church scandals, thousand-dollar suits, and parish helicopters, the basic idea that a healthy life was also a sign of favor fit right in with the gospel’s defense of riches. Health is wealth.
The prosperity gospel sold by televangelists fit—and fits—so well in many American homes because it mirrors the established national secular ethos. Some proto-form of prosperity gospel animated the life and works of men like Andrew Carnegie, who neatly tied individualism, capitalism, and wealth accumulation together in his own Gospel of Wealth. That book, a foundational defense of capitalism and income inequality based on the perceived intellectual differences and contributions of laborers and capital-owners, was also rooted in a certain form of muscular Christianity that placed health and wealth as the near-inevitable consequences of  a life well-lived, and sickness as a curse for the damned.
Although public-health circles might want to believe that the view of sickness as a curse has been supplanted by epidemiology, it’s very clear that prosperity gospel has stuck around as one of the major pillars of American health policy.
It wasn’t too long ago that the HIV/AIDS epidemic sparked a moral crisis and sparked widespread condemnation of gay communities as cursed, in a wave bigotry that stretched from schools to the White House, and still influences policy today. And as Jim Downs’s book Sick from Freedom chronicles, the original exclusion of free black people from the American health-care system—indeed one of the most enduring features of the country’s health policy—was animated both by common racism and a belief that the immense burden of sickness among freedmen was a curse for their immorality.
Aside from race, perhaps the most direct societal predictor of health is still wealth, and as America has lionized its rich men, so it has often accepted health not as a basic right, but as an aspiration. But aspiration can be inspirational, even to the sick and the poor—perhaps especially so.
After all, the prosperity gospel at least offers people some hope of living well enough to always have a shot of making it out. The reality is more crushing, and might even lend itself to nihilism: Generational poverty tends with few exceptions to breed poverty, and one of the key indicators of a person’s lifetime health quality is that of their parents.
The appeal of the prosperity gospel is intricately linked to the rise of Donald Trump, and it’s easy to see why. Much has been made of Trump’s ties to prosperity gospel-preaching televangelists, and his own wealth and success as something to which disaffected working-class people might aspire, however irrationally. But he also came along during a dire rise in opioid use, obesity, and deaths of “desperation” among poorer whites. Those health issues could be construed as a curse, especially since at the same time, the health of black and Hispanic people seemed to improve, and the Affordable Care Act seemed written to solve many of the issues of health-care access that had long wrecked communities of color.
Trump’s rise came as a preacher of the prosperity gospel. His promise to repeal Obamacare and replace it with just about nothing in particular relied as much on dissatisfaction with the current law as it did the delirious optimism of prosperity, and the idea that the real way to better America was to make life better for healthy and wealthy people, and to further link the two.
Will coal miners, unemployed auto workers, and small farmers in Appalachia fare better under the AHCA? Almost certainly not now. But if they work hard enough and have enough virtue, maybe. And at the end of the tunnel of aspiration is the favor that the AHCA’s brazen regressive health tax provides for the healthy and wealthy. It’s a moral restructuring of the health economy.
The prosperity gospel isn’t the only health-policy school out there, as evidenced by the deeply unfavorable views of the American Health Care Act, and the legions of angry voters and primary challengers House Republicans will face back home. But zeal can often defeat numbers, and men like Trump and Ryan are prosperity-gospel zealots in a way, although their inspiration may be less than divine.
If they managed what once seemed near-impossible and pass the AHCA, it might just be the harbinger of a set of policies that punish the disadvantaged, further advantage the well-off, and continue to exploit the aspirations of the masses.