DEFIANCE, Ohio — James Waltimire, a police officer on unpaid medical leave, has been going to the hospital in this small city twice a week for physical therapy after leg surgery, all of it paid for by Medicaid.
Mr. 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 Affordable Care Act. He voted for President Trump — in part because of Mr. 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,” Mr. Waltimire said the other day after a rehab 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.”
As Republicans in Washington grapple with how to meet their promise of undoing the greatest expansion of health care coverage since the Great Society, they are struggling with what may be an irreconcilable problem: bridging the vast gulf between the expectations of blue-collar voters like Mr. Waltimire who propelled Mr. Trump to the presidency, and longstanding party orthodoxy that it is not the federal government’s role to provide benefits to a wide swath of society.
If they push forward the House-drafted health bill, which could come to a vote as early as this coming week, Republicans may honor their vow to repeal what they derided as Obamacare, but also risk doing disproportionate harm to 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 and neighboring Bryan, home of 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 Dr. Neeraj Kanwal, the president of Defiance Regional Hospital.
The region has voted Republican in presidential contests for decades, but its support for Mr. Trump — he took 64 percent of the vote in Defiance County and an even larger share in most of the surrounding counties — was more resounding than for any candidate since Ronald Reagan. Yet many people here tend to have conflicting values that make repeal of the health law appealing on its face but ultimately hard to swallow.
“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, the 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 carrying a series of Democratic-leaning Rust Belt states, Mr. Trump has left his adopted party struggling to come to terms with the reality of who are now voting for Republicans — and what they expect from their government.
Nearly a million Ohio residents gained coverage under the health care act, either through expanded Medicaid or via the new marketplaces created by the law.
The governor, John Kasich, who has become one of his party’s leading pragmatists, was one of several Republican governors who carried out the Medicaid expansion. Late this past 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 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 Mr. Portman, as well as Senators 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,” Mr. Cassidy said, noting that Mr. Trump promised “he’d give them better care.”
The senator, a physician who once worked in his state’s charity hospital network, bluntly said that the philosophical debate was over and that his party ought to be pragmatic about how best to create a more cost-efficient and comprehensive health care system.
“There’s a widespread recognition that the federal government, Congress, has created the right for every American to have health care,” he said, warning that to throw people off their insurance or make coverage unaffordable would only shift costs back to taxpayers by burdening emergency rooms. “If you want to be fiscally responsible, then coverage is better than no coverage.”
A new Pew Research Center survey indicated that the number of Republicans making below $30,000 a year who believe the federal government has a responsibility to ensure health coverage for all had risen to 52 percent from 31 percent last year. And while just 14 percent of Republicans who make between $30,000 and about $75,000 last year said the government bore responsibility for health care, now 34 percent of such voters do.
“This is a function of Donald Trump engineering a takeover of the Republican Party,” said Whit Ayres, a longtime Republican pollster. “It was takeover more than assimilation, and this is the eminently predictable result.”
But now that it is Mr. Trump’s Republican Party, those who elected him will expect him to fulfill his campaign commitments.
Few Republicans can appreciate the political challenges of the Affordable Care Act like Davy Carter, a Republican and former speaker of the Arkansas House, who shepherded the law’s Medicaid expansion through his conservative legislature in a state where President Barack Obama was disdained.
“If he doesn’t do what he said he was going to do, it will alienate the very voters that put him in office,” Mr. Carter said, referring to Mr. Trump.
He has a warning for fellow Republicans who represent states with large working-class populations that, like his own, have shifted away from their Democratic roots: They did not change parties because they suddenly became free-market conservatives.
Mr. Trump, who pledged repeatedly on the campaign trail to undo Mr. Obama’s “disastrous” health law, appears torn. He is struggling between the political imperative to fulfill that promise — essential both for symbolic purposes of notching a win and for procedural reasons to go forward with an overhaul of the tax code — and his assurances that “everyone will be covered” under the new system.
“We will take care of our people or I’m not signing it,” he said when pressed in a Fox News interview last week about how his voters might fare.
If Congress moves ahead with the House version of the bill, vulnerable voters might find some allies within the health industry: Hospitals that serve the rural regions in what could be called Trump country would be particularly vulnerable. Their patients tend to be older, poorer and sicker, and their profit margins much narrower, if they make any profit at all.
Mike Abrams, president and chief executive of the Ohio Hospital Association, worries that repeal of the health law could force some hospitals to close. “But honestly,” he said, “even if they didn’t close, they would have to make some decisions that would be unwelcome by the community.”
At Defiance Regional, where Mr. Waltimire, the injured police officer, gets his care, Medicaid provides 22 percent of the revenue, up from 15 percent before the Affordable Care Act took effect. The 25-bed hospital, part of the ProMedica Health System in Toledo, has expanded mental health services and is adding a second medical office building.
Randy Oostra, ProMedica’s president and chief executive, said the Republican proposal to give states a fixed amount of money for each person on Medicaid, instead of a large share of whatever each state needs to spend, would be particularly wrenching.
“It will drive down reimbursement over time, and we’re going to start stripping care away,” Mr. Oostra said. “They may have Medicaid, but it’ll be so stripped down that they basically won’t have coverage.”
For those who get private coverage through the Affordable Care Act marketplaces, the Republican plan would provide tax credits based on age instead of income to help with the cost. Independent analyses have found that people in their 50s and 60s would be especially likely to find coverage unaffordable under the new system, which would also allow insurers to charge older people five times as much as younger ones.
Pegge Sines, 62, of rural Edgerton, Ohio, did not vote for president, but her husband, a longtime factory worker who died of lung cancer in December, was an ardent Trump supporter. They had subsidized private insurance through the health care law that covered virtually all his treatment, she said.
Ms. Sines now pays $222 a month for her insurance from the Affordable Care Act marketplace, with a tax credit of $712 covering the rest. That $8,544 annual subsidy is more than twice the $4,000 annual tax credit she would get under the Republican plan.
An aim of Republican legislation is to reduce private premiums, but Ms. Sines’s son, who along with her other two grown children signed up for Medicaid under the expansion, has been warning that their coverage could be “in trouble,” she said. She cannot believe Mr. Trump would allow that to happen.
“I can’t imagine them not keeping it like it is now,” said Ms. Sines, who runs a group home for the elderly.
Mr. Waltimire said he hoped to return to the police force, and the health benefits it provides, this year. But with no guarantee of good health — he was injured in a fall in 2009 and has had circulatory problems ever since — he also hopes other options remain available.
“It’s kind of hard for me,” he said of having free government coverage. “I’ve always worked all my life. But like my counselor said, sometimes you just have to say thank you and move forward.”
Referring to Mr. Trump, he added, “I hope he makes it so that everybody can afford insurance.”