G.O.P.’s Health Care Tightrope Winds Through the Blue-Collar Midwest

But now that it is Mr. Trump’s Republican Party, those who elected him will expect him to fulfill his campaign commitments.

Few Republicans can appreciate the political challenges of the Affordable Care Act like Davy Carter, a Republican and former speaker of the Arkansas House, who shepherded the law’s Medicaid expansion through his conservative legislature in a state where President Barack Obama was disdained.

“If he doesn’t do what he said he was going to do, it will alienate the very voters that put him in office,” Mr. Carter said, referring to Mr. Trump.

He has a warning for fellow Republicans who represent states with large working-class populations that, like his own, have shifted away from their Democratic roots: They did not change parties because they suddenly became free-market conservatives.

Mr. Trump, who pledged repeatedly on the campaign trail to undo Mr. Obama’s “disastrous” health law, appears torn. He is struggling between the political imperative to fulfill that promise — essential both for symbolic purposes of notching a win and for procedural reasons to go forward with an overhaul of the tax code — and his assurances that “everyone will be covered” under the new system.

“We will take care of our people or I’m not signing it,” he said when pressed in a Fox News interview last week about how his voters might fare.


Mr. Waltimire keeps police memorabilia at his father’s home in Napoleon.

Maddie McGarvey for The New York Times

If Congress moves ahead with the House version of the bill, vulnerable voters might find some allies within the health industry: Hospitals that serve the rural regions in what could be called Trump country would be particularly vulnerable. Their patients tend to be older, poorer and sicker, and their profit margins much narrower, if they make any profit at all.

Mike Abrams, president and chief executive of the Ohio Hospital Association, worries that repeal of the health law could force some hospitals to close. “But honestly,” he said, “even if they didn’t close, they would have to make some decisions that would be unwelcome by the community.”

At Defiance Regional, where Mr. Waltimire, the injured police officer, gets his care, Medicaid provides 22 percent of the revenue, up from 15 percent before the Affordable Care Act took effect. The 25-bed hospital, part of the ProMedica Health System in Toledo, has expanded mental health services and is adding a second medical office building.

Randy Oostra, ProMedica’s president and chief executive, said the Republican proposal to give states a fixed amount of money for each person on Medicaid, instead of a large share of whatever each state needs to spend, would be particularly wrenching.

“It will drive down reimbursement over time, and we’re going to start stripping care away,” Mr. Oostra said. “They may have Medicaid, but it’ll be so stripped down that they basically won’t have coverage.”

For those who get private coverage through the Affordable Care Act marketplaces, the Republican plan would provide tax credits based on age instead of income to help with the cost. Independent analyses have found that people in their 50s and 60s would be especially likely to find coverage unaffordable under the new system, which would also allow insurers to charge older people five times as much as younger ones.


Mr. Waltimire wonders how changes in Medicaid under President Trump, for whom he voted, could affect his own health care situation.

Maddie McGarvey for The New York Times

Pegge Sines, 62, of rural Edgerton, Ohio, did not vote for president, but her husband, a longtime factory worker who died of lung cancer in December, was an ardent Trump supporter. They had subsidized private insurance through the health care law that covered virtually all his treatment, she said.

Ms. Sines now pays $222 a month for her insurance from the Affordable Care Act marketplace, with a tax credit of $712 covering the rest. That $8,544 annual subsidy is more than twice the $4,000 annual tax credit she would get under the Republican plan.

An aim of Republican legislation is to reduce private premiums, but Ms. Sines’s son, who along with her other two grown children signed up for Medicaid under the expansion, has been warning that their coverage could be “in trouble,” she said. She cannot believe Mr. Trump would allow that to happen.

“I can’t imagine them not keeping it like it is now,” said Ms. Sines, who runs a group home for the elderly.

Mr. Waltimire said he hoped to return to the police force, and the health benefits it provides, this year. But with no guarantee of good health — he was injured in a fall in 2009 and has had circulatory problems ever since — he also hopes other options remain available.

“It’s kind of hard for me,” he said of having free government coverage. “I’ve always worked all my life. But like my counselor said, sometimes you just have to say thank you and move forward.”

Referring to Mr. Trump, he added, “I hope he makes it so that everybody can afford insurance.”

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