WASHINGTON — Republicans from rural states increasingly are worried that their party’s plan to replace the Affordable Care Act would inflict damage on vulnerable communities, especially the poor and middle-aged in isolated areas whose votes helped catapult Donald Trump into the White House.
The concerns are a byproduct of this week’s nonpartisan Congressional Budget Office analysis of the GOP replacement, which highlighted multiple ways that the health care plan falls far short of Trump’s campaign promise to keep Medicaid intact and to create a system that provides “insurance for everybody.’’
Among the 24 million additional Americans who would be expected to lose insurance because of the GOP bill, according to the CBO estimate, poor people between 50 and 64 would fare the worst.
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Specialists say people in older age groups would bear the brunt of the escalating cost of premiums that would become unaffordable to many because the bill cuts insurance subsidies for the poor. About 14 million would lose insurance by 2026 because of reductions to Medicaid, the CBO estimates, and millions more could find private insurance unaffordable.
Many are Trump voters. Of the 39 states that use the federal health insurance exchanges created by the health care law, the 10 states whose residents would lose the most under the Republican alternative all backed Trump in the general election, according to a recent analysis published by The Center for Budget and Policy Priorities.
In Nebraska, Kentucky, and even some parts of rural New England, health care issues are unique: a lack of competition for marketplace insurance, a population that trends older and poorer, employers who are less likely to provide insurance options, and a ravaging opioid addiction epidemic.
“When I look at the demographics of Maine, we are the oldest state by median age by county and we have a lot of rural areas where there is limited competition,” said Senator Susan Collins, a Maine Republican who will be a key swing vote if the health care plan reaches the Senate floor. “Those are concerns of mine.”
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The Trump administration is selling the bill as a victory for free markets and consumer choice. But its effects on rural Americans are among multiple stumbling blocks for GOP and Democratic senators who are balking at the House bill, which Speaker Paul Ryan unveiled last week.
Senator Shelley Moore Capito, a Republican from West Virginia, said a key concern for her is whether the House bill is “sufficiently helping those in the lower-income rural older population, which is increasingly a large part of my state.”
In an interview with ABC’s “This Week,” Senator Tom Cotton of Arkansas said passing the bill, as it stands now, could have dire consequences for the party at large.
“I’m afraid that if they vote for this bill, they’re going to put the House majority at risk next year,” Cotton said.
The Affordable Care Act, Barack Obama’s hallmark domestic policy, offered incentives to states to expand their Medicaid programs, a move that helped millions of people gain health insurance, particularly in rural communities.
The plan unveiled by Ryan would reverse that Medicaid expansion. Under the GOP plan, some specialists foresee a health care system that would cast aside the most disadvantaged and displaced, in favor of helping insurance companies and the wealthy.
For example, under the Republican plan, a single person making $26,500 would earn the same tax credit toward their health insurance as someone making $68,200. Plus, families with incomes in the top 1 percent would earn an average tax cut of $37,000 a year, according to an analysis by the Tax Policy Center, a nonpartisan think tank.
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“It’s a double whammy of phasing out Medicaid expansion and making it more expensive to get marketplace coverage,” said Dee Mahan, the director of Medicaid Initiatives at Families USA, the research firm dedicated to consumer health care.
Much of the decrease in insurance coverage is a direct result of a shift in political philosophy.
The Affordable Care Act required Americans to buy health care insurance using what is known as an “individual mandate” and provided substantial government subsidies to those who could not afford to buy coverage on their own. The Republican plan eliminates the individual mandate and dramatically slashes the subsidies.
The White House, Ryan, and other proponents say eliminating the mandate and other regulations would foster competition between insurance companies, decreasing the costs of premiums and expanding access to insurance plans.
The bill is taking fire from all sides.
Hard-line conservatives blasted the bill as “Obamacare lite” for its continued reliance on tax credits and failure to more quickly scrap the current law’s Medicaid expansion. More moderate Republican senators, including a number from states with large rural populations, fretted about the steep coverage losses their constituents faced — some of which comes from the Medicaid expansion their colleagues so fiercely oppose.
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“There is a solution for House Leaders that conservatives have offered: abandon Obamacare Lite now. It is bad law & it can’t pass,” Senator Rand Paul, a Kentucky Republican and a trained physician, tweeted Tuesday morning.
The White House has bristled against the bipartisan pushback, and announced this week that the president will soon hold a rally in Kentucky and Tennessee to directly make his case to the American people.
On Tuesday, during a briefing by White House press secretary Sean Spicer, the administration sought to downplay the recent CBO report.
When asked specifically if he believed the numbers, Spicer said “CBO coverage estimates are consistently wrong” and that “the president is proud of” the bill.
During the Obama administration, Spicer and Trump repeatedly used CBO numbers to attack Obama.
“Our idea is that if you bring down costs to fit their budget, there’s a higher likelihood they can find something they like at a price they can afford,” Spicer said Tuesday.
Representative Ann McLane Kuster represents Coos and Grafton counties in New Hampshire, two largely rural areas that have experienced significant drops in their uninsured population since the Affordable Care Act passed in 2010.
In an interview, Kuster, a Democrat, said Coos County’s uninsured rate dropped 10 percent because of the Affordable Care Act and that Grafton’s rate is now at 5 percent, a record low. She characterized the Republican proposal as disastrous for her district, which includes communities that backed Trump during the general election.
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“Finally, people have been able to come in for preventative care, rather than just showing up at the emergency room,” Kuster said.
Plus, because more of the population now has insurance, hospitals could stop “cost shifting to everyone else” and more opioid addicted individuals are getting the access to treatment they need, she said.
The proposed repeal of the health care law “couldn’t come at a worst time,” Kuster said. “Finally people are starting to get access to treatment, and half of the people that get treatment are able to get treatment because of ACA. They’d lose that.”
Senator Jeanne Shaheen, a Democrat from New Hampshire, echoed her concerns regarding how repealing the Affordable Care Act could affect addiction treatment.
“This bill would be a disaster for New Hampshire,” Shaheen said. “We have thousands of people who are getting treatment now because of the expansion of Medicaid and they would be thrown out of that treatment and there aren’t any other options.”
Astead W. Herndon can be reached at astead.herndon@globe.com. Follow him on Twitter @AsteadWH