Again and again, President-elect Donald Trump presented himself as the coal miners’ candidate. During the campaign, he promised to bring coal back into the economy, and jobs back into struggling Appalachian towns.

But now some in coal country are worried that instead of helping, Trump’s first actions will deprive miners — and their widows and children — of the compensation they can receive if they are disabled by respiratory problems linked to breathing coal mine dust.

That’s because buried in the Affordable Care Act are three sentences that made it much easier to access these benefits. If Trump repeals Obamacare — as he vowed to do before the election — and does not keep that section on the books, the miners will be back to where they were in 2009, when it was exceedingly difficult to be awarded compensation for “black lung” disease.

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“You couldn’t ever win back then,” said Sue Toler, a coal miner’s widow in Huntsville, Tenn., of claims for black lung benefits. “It didn’t matter what kind of evidence you had.”

Of the 27 years her husband Arvis worked for Eastern Associated Coal in Kopperston, W.Va., 16 of them were spent underground. When he had to stop working because of breathing trouble, a doctor ordered chest X-rays and saw the telltale dark scars on his lungs. His doctor’s diagnosis, his widow said, was coal workers’ pneumoconiosis — or black lung.

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That was in 1993. Five years later, after two appeals and innumerable examinations with doctors chosen by the coal company, Toler was denied benefits, in part because he’d smoked cigarettes before his diagnosis.

At the time, to qualify for benefits, miners had to prove not only that they were disabled because of breathing problems, and that they had coal workers’ black lung, but that their disability was caused by their years in the mine.

It was “almost impossible,” said Phil Smith, a spokesman for the United Mine Workers of America. “The vast majority of people were denied benefits. People would take these cases through the black lung court system and they would be denied because the companies could sow the shadow of a seed of a doubt.”

The Affordable Care Act changed that. Under “Miscellaneous Provisions” is a small section sponsored by a self-proclaimed “child of the Appalachian coalfields,” the late West Virginia Democratic Senator Robert Byrd.

The Byrd Amendments shifted the burden of proof from the miners onto the mining companies. If a miner has spent 15 years or more underground and can prove respiratory disability, then it is presumed to be black lung related to mine work, unless the company can prove otherwise.

“Often the person whose job it is to do the convincing loses,” said Evan Smith, a lawyer for the nonprofit Appalachian Citizens’ Law Center, who represents many miners affected by black lung. That change had a significant impact: In 2009, 19 percent of claims for black lung benefits were successful; in 2015, that percentage had jumped to 28.

The Byrd Amendments also had a huge effect on the families relying on that compensation. Before their enactment, when a miner died, his widow would keep getting compensation only if she could prove that her husband died because of black lung — a process that often took years, if it was successful.

Now, with a bit of paperwork, she keeps getting a portion of the money the family got when her husband was alive. The amount changes according to the number of family members dependent on the coal miner or widow. At the top end, a beneficiary with three or more dependents gets $1,289 a month, while a single beneficiary gets $644.50.

These changes in the Affordable Care Act not only meant that Arvis Toler ended up being awarded benefits shortly before he died in 2015, but also that his 70-year-old widow, Sue, has continued to receive compensation every month.

The coal industry opposes these rules. “Our concern back then, which continues today is that … compensation is not based on occupational disease, but rather this is becoming a supplemental pension program, and that was not what it was ever intended to be,” said Bruce Watzman, vice president of the National Mining Association.

But, he said, industry representatives have other priorities than undoing Byrd’s changes, such as reversing what he called “Obama’s war on coal.”

Even so, many coal miners and their advocates are concerned that their fates are tied to a piece of legislation that has, in a certain sense, just lost an election, especially in coal-producing states such as Kentucky and West Virginia. Lawyers working on this issue are worried that repeal of the ACA could mean no compensation for new claimants and the potential loss of benefits for anyone who won them since the law passed.

The Trump transition team did not respond to STAT’s request for comment. Since the election, though, Trump has softened his rhetoric about completely doing away with Obamacare, and miners have advocates in the House and the Senate. “Repealing and replacing Obamacare will be a top priority for the new Congress, but Congressman Rogers has advocated for a piecemeal approach … many Members of Congress have acknowledged that some portions of the law are worthy of continuation, such as critical protections for coal miners,” said a spokesperson for US Representative Hal Rogers, a Kentucky Republican who chairs the powerful House Appropriations Committee.

The offices of Democratic Senators Joe Manchin of West Virginia and Bob Casey of Pennsylvania said they would fight any attempt to remove these protections from coal miners. A spokesperson for Kentucky Republican and Senate Majority Leader Mitch McConnell said by email that the senator has no “announcements on any legislative action for next Congress.”

Evan Smith, the attorney, warned against complacency. “I want to make sure that coal country doesn’t assume that they are going to be taken care of just because a lot of our political leaders have voiced support for our region,” he said. “I wish I could be more optimistic that they truly would keep their promise.”

Dr. Cecile Rose, director of the Miners Clinic of Colorado and a professor at National Jewish Health in Denver, noted that black lung benefits can be especially vital for the many former miners who don’t have pensions. “Retired miners, a lot of them have also lost their pensions because of the bankruptcies that many of the coal mines have declared,” she said. “They may be hanging on by a thread.”

The uncertainty about these benefits is even more worrisome to her because of evidence showing an increase in both the prevalence and severity of black lung cases.

Sue Toler takes issue with Trump’s way of talking, and she isn’t sure about his plan to get miners back to work. “I’ve got mixed feelings about that … I watched my husband suffer,” she said. “But if it’s good for the country, then I’m all for it.”

To her, though, it would be sad if black lung benefits like her husband’s got taken away after the 22 years of suffering that preceded his death.

“He couldn’t breathe, and that just kept getting worse. He just died a little bit every day, and there was nothing you could do about it,” she said. “Words can’t describe what somebody goes through when they are dealing with black lung.”

Her brother-in-law is “dealing with that now,” she added. “I’ve seen him walk through the house when it looked like he was going to draw his last breath, and I had held my own breath until he was able to set down.”