House Republican leaders heard criticism from right and left about their proposed replacement for the Affordable Care Act. Now they have floated adjustments to the proposal, the American Health Care Act, that signal a first preference for addressing the concerns voiced from the right.

They want to give states the option of abandoning protection for those with preexisting conditions. They also want to permit states to shrink the essential benefits requirement, that coverage include such things as prescription drugs, mental health care, maternity care and inpatient and outpatient care. These steps appear designed to please the House Freedom Caucus. Its members have pressed for a reduced government role in the individual insurance market.

Why House Republicans, let alone the Trump White House, would take this path is something of a puzzle. One poll shows just 17 percent of Americans support their initial plan, which would result in 24 million people losing their insurance coverage during the next decade. Add the proposed options for states, and the fallout likely would be worse.

Is that a formula for expanding public support or attracting a majority in the Senate? Perhaps the purpose is simply to act, or to get on the record any measure that repeals and replaces.

One of the clear advances of the ACA is the protection for people with preexisting conditions. Insurers are barred from charging more based upon a person’s medical history. This is achieved through the concept of “community rating,” establishing, essentially, one premium rate for all. Allow states to back away, and insurers would return to how things worked before the act. The sick would face soaring premiums and narrowing coverage, many unable to find affordable health insurance.

Republicans seek to reassure the uninsurable by requiring states to set up high-risk pools. As it is, this idea has been tried by states in the past. It has proved inadequate, delivering exorbitant premiums and miserable coverage, from high deductibles to annual and lifetime limits on benefits. More, some find they are excluded for up to a year and run into long waiting lists.

Removing the requirement for essential benefits would reduce premiums for some (less coverage, less cost). The broader impact would be similar to erasing the protection for preexisting conditions. Those who are sick, say, with a chronic condition, depression, even cancer, would likely encounter a market that fails to offer the affordable insurance they need.

Women again would pay more than men for coverage.

What frequently is overlooked in the debate over repeal and replace is just how dysfunctional and punishing the health care market was before the ACA. Now House Republicans are looking to go back.