DEFIANCE, Ohio -- James Waltimire, a police officer on unpaid medical leave, has been going to the hospital in this small Ohio city twice a week for physical therapy after leg surgery, all of it paid for by Medicaid.
Waltimire, 54, was able to sign up for the government health insurance program last year because Ohio expanded it to cover more than 700,000 low-income adults under the 2010 Patient Protection and Affordable Care Act.
He voted for President Donald Trump -- in part because of Trump's support for law enforcement -- but is now worried about the Republican plan to effectively end the Medicaid expansion through legislation to repeal the health care law.
"Originally the president said he wasn't going to do nothing to Medicaid," Waltimire said after a recent rehabilitation session. "Now they say he wants to take $880 billion out of Medicaid. That's going to affect a lot of people who can't afford to get insurance."
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Republicans in Washington are grappling with how to keep their promise of undoing the greatest expansion of health care coverage since 1964-65 under the Johnson administration. They face bridging the gulf between the expectations of blue-collar voters like Waltimire, who propelled Trump to the presidency, and long-standing party orthodoxy that it is not the federal government's role to provide benefits to a wide swath of society.
If they push forward on the House-drafted health bill, which could go to a vote as early as this week, Republicans may honor their pledge to repeal "Obamacare" but risk harming the older, working-class white voters who are increasingly vital to their electoral coalition.
Many of those voters live in small Midwestern cities like Defiance, Ohio, and neighboring Bryan, home to a candy company that makes Dum Dum lollipops but has moved many of its jobs to Mexico. Though unemployment is low in the region, where farmland stretches for miles between towns, the slow erosion of manufacturing has taken a toll, and "what's left in our communities are lower-paying jobs," said Neeraj Kanwal, president of Defiance Regional Hospital.
The region has voted Republican in presidential contests for decades. Trump received 64 percent of the vote last fall in Defiance County and an even larger share in most of the surrounding counties. That support was more resounding than for any candidate since Ronald Reagan. Yet many people in the region tend to have conflicting values that make repeal of the health law appealing on its face but ultimately hard to swallow.
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"People in this community are very conservative. They struggle with the federal budget deficit, and they like the idea of personal responsibility," said Phil Ennen, president and chief executive of Community Hospitals and Wellness Centers, which has a 75-bed hospital in Bryan. "But at the same time, we have a lot of friends and family and neighbors who just don't have a lot going for them. There is a population out there that needs Medicaid. That's the dilemma."
It is a daunting paradox for a party that, at least in theory, was once unified around a belief that Washington should be tamed, not empowered. But by winning the White House under the banner of economic nationalism and prevailing in several Democratic-leaning Rust Belt states, Trump has left his party struggling to come to terms with the reality of who is now voting for Republicans -- and what they expect from their government.
Nearly 1 million Ohio residents gained coverage under the federal health care act, either through expanded Medicaid or via the new marketplaces created by the law.
Gov. John Kasich was one of several Republican governors who carried out the Medicaid expansion. Late last week, he joined some of them in a letter to the congressional leadership requesting that the new health care bill be changed so that the Medicaid expansion is not ended entirely.
The state's Republican senator, Rob Portman, has been among the most outspoken Republican lawmakers expressing concern over any attempt to quickly end the Medicaid expansion. But the Republican congressman who represents Defiance and the surrounding area, Bob Latta, is an ally of the House leadership and has supported the replacement bill.
For all the focus on demands by the party hard-liners that the repeal-and-replace bill be less expansive, there is also rising concern among mainline Republicans from states with large numbers of lower-income whites about a backlash. The group includes Portman, as well as Sens. Lisa Murkowski of Alaska, Tom Cotton of Arkansas, Bill Cassidy of Louisiana and Shelley Moore Capito of West Virginia.
"The folks who Hillary Clinton called the 'deplorables' are actually those who want better coverage, who we'd be hurting if we don't change this bill," said Cassidy, noting that Trump promised "he'd give them better care."
Information for this article was contributed by Abby Goodnough and Jonathan Martin of The New York Times.
A Section on 03/19/2017