Although the draft plan repeals the tax-based individual mandate, it re-establishes a kind of mandate through its incentive to maintain continuous health-insurance coverage. For people not covered by employers or public insurance who have to purchase insurance on individual, small group, or exchange markets, this proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months, and also for young adults who don’t enroll in coverage as soon as they age out of their parents’ plans, a surcharge that would not be remitted as taxes to sustain the system, but would be paid as profits to insurers. The effects of this potential measure on individuals’ pockets are potentially limited by a reduction of federal oversight over what can be considered health-insurance coverage, which would allow people to avoid penalties by purchasing barebones coverage.

After reforming Medicaid, repealing the taxes and mandates of Obamacare and establishing continuous-coverage requirements, the last major reform of this preliminary scheme is to replace the cost-sharing reductions and premium tax credit subsidies of Obamacare’s exchanges with a refundable tax credit. Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person’s market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. So while older people with more health needs receive more than “young invincibles,” lower-income people who tend to have more pressing health needs would have even less ability to take care of those needs given their existing ability to pay.

The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states’ ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face.

Those health issues are serious, and contribute to much of the climbing mortality among middle and lower class white Americans today. The opioid epidemic is ravaging rural America, as are the creeping effects of environmental degradation and climate change. People like coal miners in Trump country in Kentucky and West Virginia are on the frontiers of several developing health crises, and per-capita spending caps on Medicaid would only further limit their states’ ability to respond.