Matthew Frankic, a health insurance broker and Republican voter, makes his living signing people up for the Affordable Care Act, better known as Obamacare.

Since the law went into effect in 2014, he has seen flaws. Each year, health insurance in his section of southern Indiana has seemed to cost more, and fewer doctors and hospitals seemed to accept it.

But he supported the unpopular Republican effort to reform the law until he heard one group would have to pay more for insurance: those who are already ill.

“I am not for what they brought out,” said Frankic. “And my main reasoning behind that is because of pre-existing conditions.”

“Pre-existing condition” was once insurance industry jargon, but is now common parlance to refer to Affordable Care Act (ACA) protections that bar health insurance companies from denying coverage to people based on their health.

Prior to the ACA, everything from obesity to depression could disqualify people from insurance. Those who bought their own insurance or received it through groups such as small businesses were most vulnerable. Employers provide health insurance to most Americans.

“I have too many clients that I personally know that have – and had – pre-existing conditions,” Frankic said. “I can’t back anything that basically throws them back out to where they were. It doesn’t seem like we’re advancing anywhere. I’m really not excited about that and that’s my main thing.”

Other Trump supporters, such as the North Carolina maintenance worker Stuart Morris, 45, are more frank.

“Healthcare in our nation is a disaster,” he said. “Insurance companies rule this country, and whether it’s Obamacare or it’s something that the Republican party puts into place under Trump, I feel like either way it’s probably going to be a disaster for working-class Americans.”

Republicans resurrected the health bill after a stunning March defeat, which left Trump without a coveted legislative victory. Though Barack Obama’s signature health law insured 20 million Americans, it remained controversial as some saw monthly insurance payments shoot up.

The Republicans’ plan was thought dead, until a New Jersey lawmaker concocted an amendment to resurrect the bill. In order to pass it through the very conservative US House of Representatives, the amendment allowed states to opt out of Obamacare’s most important consumer protections.

“The underlying structure of the House bill is the same,” said Edwin Park, vice-president of health policy at the Center on Budget and Policy Priorities. “This isn’t really about somehow slowing the growth in healthcare costs. This is about shifting costs. So it’s cutting federal spending on health coverage, but in turn shifting the cost ... on to individuals and families in terms of their out-of-pocket costs.”

Sisters Dana Thynes and Tamara Evens. ‘There are people who simply, absolutely cannot pay for themselves ... the government absolutely has to step in and help out.’ Photograph: Courtesy Tamara Evens and Dana Thynes

There are three main provisions in the ACA that keep sick people from being pushed out of the insurance market. First, insurance companies have to issue policies to people who are or have been sick. That is called “guaranteed issue”. Next, insurance companies cannot charge the sick more than the healthy. That is called a “community rating”. Lastly, the law requires insurance to cover a list of benefits, such as prescription drugs and maternity care, called “essential health benefits”.

The Republican health bill technically still requires insurance companies to issue policies to sick people, but because it guts “community rating” and “essential health benefits” standards, policies for people who have had cancer or need maternity coverage will be much more expensive.

The bill gives the job of gutting standards to states, allowing lawmakers to apply for “waivers” to winnow down benefits and let insurance companies charge the sick more. However, Republicans have created a built-in incentive to offer people fewer benefits: dramatically skimpier tax credits. State lawmakers will need to decide whether to exclude benefits so many people can afford plans with little coverage, or keep comprehensive coverage only to push out most regular people.



“It’s not that the policy that costs $45,000 wouldn’t include coverage for my pre-existing condition, it’s just that I will never be able to afford that policy,” said Linda Blumberg, a health policy expert with the Urban Institute, about a hypothetical scenario under the Republican bill. That would bring consumers back to where many were pre-ACA, when cheaper policies didn’t cover things like maternity care. “So, I can buy that policy, but if I’m pregnant my maternity care isn’t going to be covered.”

Republicans argue their bill would provide health benefits to the sick through “high-risk pools”, or insurance provided to the sick subsidized by the American taxpayer. However, according to the last assessment of the Republicans’ bill, in an earlier form, risk pools wouldn’t come close to providing coverage for the additional 24 million people that would likely lose insurance thanks to the bill.

The bill has “anemic” support from both Republicans and Americans broadly. Just 21% of Americans support the bill, according to a Quinnipiac University poll released on Thursday, including a minority of (48%) of Republicans. “... Every listed party, gender, educational, age and racial group opposes the plan,” Quinnipiac pollsters said.

Despite political polarization, polls show Americans agree that protections from pre-existing conditions should remain, even if Republicans remain broadly supportive of efforts to repeal and replace the ACA.

“Fifty-two per cent of Democrats and 48% of Republicans oppose allowing states to opt out of requiring insurance companies to cover pre-existing conditions,” said Kyle Dropp, chief research officer at Morning Consult, about a recent poll conducted with Politico. “This is one issue where Democrats and Republicans largely agree.”

Dana Thynes, a music teacher in rural Petersburg, Alaska, who voted for Trump, said: “There are people who simply, absolutely cannot pay for themselves, and a friend comes to mind whose baby cost over $1m.” Thynes has non-traditional insurance through the religious group.

“The government absolutely has to step in and help out in cases like that.”

What’s more, excluding pre-existing conditions would probably hit Trump’s core constituency.

The top 10 states with the most residents believed to have pre-existing conditions all voted for Donald Trump, according to a 2016 Kaiser Family Foundation analysis. However, those states – West Virginia, Mississippi, Kentucky, Alabama, Arkansas, Tennessee, Oklahoma, Kansas, Louisiana, Indiana and Missouri – were also less likely to feel the benefits of the ACA. Just four expanded a public insurance program for the poor, called Medicaid, that insured 11 million Americans nationally.

“Honestly, I don’t even know where you go with it, it’s such a mess,” said Morris, who pays $240 per month for insurance through his employer. “It’s a battle that the public is caught up in. What can you do at this point? What can we do to say somebody’s going to enact something that works a little better?” Morris called affordable insurance a “moral obligation”, and said he believed the US should adopt single-payer health insurance.

“A lot of people have said: ‘Republicans need to put up or shut up,’” after years of the party campaigning to repeal Obamacare, Frankic said. “Well, so they’ve done something, and what is it? It’s nothing. It’s horrible. I don’t know who’s going to be happy at them.”

Frankic said he had not decided whether he would vote out a representative because of their health insurance vote, but he wouldn’t rule it out. “I would definitely, without a doubt, put that on the plate when I’m weighing my options.”