In a 60 Minutes interview from 2015, President Trump assured the nation he would come up with an affordable, universal health insurance plan to replace the Affordable Care Act (ACA). However, his recent attempt to repeal and replace the ACA was struck down by the opposition because of concerns of excluding low-income working-class or elderly people from its benefits—the very demographic groups that landed Trump in the White House.

Though his healthcare bill was pulled from consideration in the House on March 24th, Trump recently told lawmakers that he expects more deliberations on a healthcare plan. Considering the possibility of new healthcare legislation after his failed attempt in repealing the ACA, it is important to understand the effects of his proposed health care policies on populations that supported his bid to the Oval Office. Such analysis will provide insight into the repercussions of new legislation.

West Virginia, a state in which Trump earned over sixty percent of the popular vote is home to the demographic of Trump voters who are most vulnerable to losing their coverage under a new health care plan. As of 2017, around ten percent of West Virginia’s population is enrolled under the Medicaid expansion. As many as 34,000 West Virginians signed up during the enrollment period which lasted from November 2016 to January 2017. The expansion assists in covering health expenditures related to annual check-ups, the purchasing of prescription drugs, and treatment for substance abuse.

Coverage of substance abuse rehabilitation or therapy is particularly important for the population of West Virginia. At the center of the opioid epidemic, the state has the highest prescription drug overdose rate in the countryfortunately, Medicaid allows for over 20,000 West Virginians seek help for opioid addiction.  Should the GOP rally behind Trump such that they can pass a new healthcare bill, West Virginians afflicted with addiction who are covered under the Medicaid expansion may find themselves lacking the treatment or counseling they need.

One of the foremost concerns arising with the GOP’s new healthcare plan was affordability. Under Obamacare, the maximums for out-of-pocket expenses were capped at up to $7500 per individual based on income. In contrast, the GOP’s new healthcare plan would have provided no maximum for such expenses. While Obamacare provided subsidies to reduce the cost of health coverage, the new plan promised only refundable tax credits based on age (instead of income) with refundable tax credits being capped at $4000 for those over the age of sixty.

How effective would these refundable tax credits be in making health coverage affordable? According to the Kaiser Family Foundation, individuals in West Virginia would have witnessed a rise in premiums even with the new plan’s tax credits. For example, in McDowell Countyan area that voted overwhelmingly for Trump in the 2016 electionthe premiums would have nearly doubled. The increasing burden on individuals to subsidize their own health insurance would pose a financial burden on many in West Virginia. In a study conducted by Massachusetts Senator Elizabeth Warren in 2007, medical debts were found to cause over half of the bankruptcies in the area. Consequently, fewer individuals would be eligible for coverage, dragging down enrollee counts.

Concerns have also arisen about President Trump’s pledge to increase competition between and the diversity of insurance plans. Under the GOP plan, as many as 29,000 West Virginians currently receiving financial assistance to purchase health coverage would find themselves unable to afford insurance. Without the ability to pay, they would be forced to withdraw from insurance plans; insurance companies would then be catering to a smaller market of clients.

The new plan would also repeal the individual mandate which requires all Americans to purchase health insurance. This change would allow healthier individuals, who are less in need of coverage, to remain off of insurance plans. With fewer healthy clients on their rolls, insurance companies have fewer individuals to whom they can pass on the costs of care generated by sicker populations. This necessitates raising premiums to account for their expenditures on ‘riskier’ populations. Such a rise in premiums will further disincentivize healthy individuals’ purchasing insurance plans, again forcing an increase in premiums and perpetuating what is known as the insurance death spiral.

In a state afflicted with the highest overdose rate coupled with economic deprivation, pushing individuals off their health insurance will be detrimental to their health. According to Danny Scalise, West Virginia native and Director of the West Virginia State Medical Association, “Anybody who cares for these patients agrees that it’s not going to be good.” Without coverage, many addicts will also be unable to find resources or support to combat their affliction.

Another provision under the new plan that would impact the universality of healthcare is the continuous coverage mandate. In West Virginia, unemployment has increased as the coal-mining industry continues to shrink and lay off miners. Since 2013, more than 10,000 West Virginian coal miners have lost their jobs. Considering a majority of Americans are insured through their employers, this trend is particularly alarming.

Jobless West Virginian coal miners would no longer have the benefit of coverage provided by an employer, and the Affordable Healthcare Act’s continuous coverage provision would only exacerbate the situation. Under the new provision, individuals may have faced up to a thirty percent spike in health insurance premiums for lapses in coverage greater than sixty days. This means individuals would have 60 days from the point of unemployment to find another job that provides health insurance, or else purchase their own insurance to avoid a spike of up to 30% in their premiums for an entire year.

“Insurance companies don’t want individuals cherry-picking premiums, and unemployed people will be casualties in that,” explained Scalise.

With the proposed repeal of the individual mandate under the new plan, the challenges associated with coverage loss will afflict masses of Trump voters across the state who have lost jobs from the decline of major industries. Ultimately, the continuous coverage penalty is punishment for those who find themselves unemployed and unable to find coverage within an unreasonably short time-frame.

Foreseeing potential harm to their constituents, West Virginia’s U.S. Senators expressed their disapproval for the new legislation. Senator Shelley Moore Capito of West Virginia joined three other Republican Senators in sending a letter to Senate Majority Leader Mitch McConnell expressing their concerns for individuals who would be hurt by the implications of the unveiled healthcare bill. We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services,” they expressed jointly in a letter.

Senator Joe Manchin seemed to agree, stating in a CNN interview with Don Lemon that “West Virginians might not know who gave them their coverage, but they’ll know who took it away.”

As seen evidenced by the senators’ statements, Trump’s new healthcare plan would have severely impacted the very populations that voted him into office. As the healthcare debate rages on, Trump will soon have to make a decision between maintaining the integrity of his current bill or compromising to better serve the populations put him into office.