You would have had to have been in a coma for the last six years if you didn’t know that many, many Americans hate the Affordable Care Act, especially when it goes by the name “Obamacare.”

But you can be excused if you didn’t realize that they all don’t have the same reasons for hating it.

This is what Republicans in Washington are discovering, which is what is making it so hard to repeal and replace the ACA, the signature policy achievement from the Democrats’ brief two-year stint of controlling both the White House and Congress, the same levers of power that Republicans now hold.

For instance, people say they don’t like the program because of the cost. But what cost are they talking about?

Some Republicans are complaining about the taxes it collects from high-income individuals and companies that gained demand for their services in a subsidized market. But other critics are talking about the high premiums and deductibles on plans offered through the health care exchanges.

You can’t please both sides: If you cut the taxes, the plans will get more expensive. If you increase the subsidies to make the plans less costly, you can’t afford to cut the taxes. And, by the way, the ACA actually reduces the deficit, so repealing it would cost everybody more even as millions of people lost their coverage.

As President Trump himself said last week, “Nobody knew that health care could be so complicated!”

That wasn’t the only thing the president said about health care. In his well-received speech to a joint session of Congress on Tuesday, Trump spoke in slightly more detail about the shape that an ACA replacement should take, and listed five principles for a replacement plan. Each reveals another level of complexity.

“First, we should ensure that Americans with pre-existing conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.”

Republicans will have to decide whether “should ensure … access” means the same thing as “should have coverage” and whether a “transition” means a transition to other coverage or to no coverage at all.

“Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government.”

Tax credits aren’t free, and the president appears to be siding with the people who complain that health insurance is too expensive to buy under the ACA. But finding the money to pay for the subsidies is apparently Congress’ problem

“Thirdly, we should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”

This sounds like a reference to Republican efforts to turn Medicaid into a block grant program, which analysts predict will leave many people out, especially if the federal government caps spending.

Medicaid rolls grow and shrink along with economic cycles. When a recession hits and people lose their jobs, they become eligible; when they get back to work, they go off Medicaid. A flat amount from Washington would create a financial crisis in Maine every time we hit a period of high unemployment.

“Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance – and work to bring down the artificially high price of drugs and bring them down immediately.”

Medical malpractice reform is perennially popular during campaigns, but studies show it would have limited impact on health care costs. Prescription drugs, on the other hand, are a major driver of health care costs, putting coverage out of reach for millions of Americans. If Trump could get Republicans in Congress to give up their historical objection to regulating drug prices, he might indeed make coverage affordable without high subsidies.

“And finally, the time has come to give Americans the freedom to purchase health insurance across state lines – which will create a truly competitive national marketplace that will bring cost way down and provide far better care.”

This has been part of Republican orthodoxy for decades, but there is no evidence that it would drive costs down. It’s not just state regulation that keeps insurance companies from setting up shop in Maine – it’s also the underlying cost of caring for people here, because our population is older and sicker than those in other parts of the country.

The most complicated problem Trump faces is political. Republicans have run for office for years claiming that repealing Obamacare would be easy: It’s not, and not just because 20 million more people have health insurance than had it before.

Even Republicans don’t agree on why it is that they hate the program, so they can’t agree on how to fix it.

Until they do, it would be irresponsible to go any further down the road to repeal.

Only subscribers are eligible to post comments. Please subscribe or to participate in the conversation. Here’s why.

Use the form below to reset your password. When you've submitted your account email, we will send an email with a reset code.