In Elk River, Minn., where Donald Trump earned six in 10 votes last November, there is confidence in Trump the president but some unease about the health plan he’s pushing to replace the Affordable Care Act.

The Republicans’ proposed American Health Care Act (AHCA) would reportedly cut the number of people with health insurance by 14 million in 2018 and increase costs for older adults who tend to use more medical care. Details of the plan may change as it makes its way through Congress, but for now it appears to fall short of Trump’s pledge to replace Barack Obama’s ACA with cheaper and better coverage.

“They say it’s repeal and replace,” said Bill Zacharda, having breakfast Thursday with the usual crew at the Olde Main Eatery in downtown Elk River. “What it should be is, work and fix.”

As proposed by U.S. House Republicans, the AHCA would remove a mandate requiring Americans to be insured. It also would reduce federal spending by capping state grants to pay for the Medicaid health program for the poor and disabled, and by basing subsidies on age rather than income to help working Americans afford private insurance.

The Congressional Budget Office estimated the changes would trim the federal deficit by $337 billion over the next decade. Further analysis by the Kaiser Family Foundation found the changes could save money for some, but would increase health plan costs for lower-income, white, rural Americans — the backbone of the Trump voting bloc that swept him to victory in November.

“That’s a little scary that people who have something are probably going to end up losing,” said Joy Schober, 61, who sat across the breakfast table from Zacharda.

Schober’s low income as a part-time child care worker earned her Medicaid coverage this year, but she has a stack of unpaid bills from when she couldn’t afford private insurance and needed treatment of a shoulder injury.

“I don’t open them anymore,” she said.

Analysts have predicted that states would cut Medicaid eligibility under the Trump-endorsed plan because it would cap their federal aid — meaning that benefits for working adults such as Schober could be in jeopardy.

Zacharda, 63, is a Trump voter with a lawn care and snowplow business who could end up with higher costs. Income-based subsidies shaved his monthly premium this year to $244, a third of what he used to pay for health insurance. But the Kaiser analysis shows that someone in his age range and income bracket in Sherburne County could end up paying $2,900 to $4,500 more for coverage due to the Republican plan’s switch to age rather than income in determining subsidies.

Though the AHCA presents personal risks, Zacharda is eager to see if Trump and the Republican Congress can come up with something better. Even a modest increase in his business, theoretically a good thing, would reduce his subsidies under the Affordable Care Act and put health insurance beyond his budget.

“I make $10,000 more and I could be paying $1,000 a month again,” said Zacharda, who drew smirks around the table at his solution. “I just won’t work as hard today!”

Going without coverage

The mixed reactions in Elk River match those nationally in Kaiser’s recent tracking poll, which found that 48 percent of people believe the Republican plan would decrease the number of people with health insurance and increase the cost of those with insurance.

Results among Republicans themselves weren’t as strong; 22 percent said the AHCA would cause more people to be uninsured.

Political reactions are varied as well. U.S. Rep. Erik Paulsen, a Republican, hailed the AHCA plan for “giving patients immediate relief” from skyrocketing premiums. But Elk River’s congressman, U.S. Rep. Tom Emmer, also a Republican, is reviewing the bill and seeking opinions.

“He believes, unlike the lawmakers who passed Obamacare, it is important to know what is in a bill before we vote on it,” said Emmer spokeswoman Rebecca Alery.

The breakfast group in Elk River last week bemoaned problems that aren’t addressed by Obama’s health care law or the plan Trump supports, including escalating drug costs that have them going without prescriptions.

Reactions were simpler for those without insurance: Anything is better than what they can’t afford now.

Chad Belanger, Olde Main’s cook, said two jobs aren’t enough to make health insurance affordable. Even if he loses hundreds in penalties for violating the federal mandate, that would be cheaper for him, he said.

“That’s only one month of insurance,” said Belanger, 30, a Trump supporter who skipped recent treatment for what he figures was a broken knuckle.

Around the corner from the cafe, travel agent Penny Anderson is dreaming of a trip to Punta Cana but instead is saving for medical care in case she, her husband or two kids get sick. The family became uninsured this year when monthly premiums increased to $1,200.

“It’s really scary,” she said.

Anderson, who expects to pay thousands in federal mandate penalties, hopes Trump’s approach will help. “He’s a businessman. I really think he could do some good things with health care,” she said.

Penalties, higher premiums

The insurance mandate would be replaced under the AHCA with a 30 percent premium penalty for the uninsured if and when they return to the individual market. The plan also would keep the requirement for insurers to accept all customers, even those with costly diseases.

But it would give insurers the ability to raise premiums fivefold on older adults, who tend to be more expensive and more frequent users of their benefits. Current restrictions only allow plans to triple premiums on this age group.

Fay Niederhaus worries that the increases of the Republican plan could cost her the affordable insurance she has now, at a time when her savings are invested in her start-up Olive A Day business in Elk River.

The 61-year-old, who wrote in Ohio Gov. John Kasich for president last November, is hopeful about her gourmet grocery, which sells olive oils and vinegars. Doctors are referring customers to her because of olive oil’s benefits.

But if profits are lean at a time when the AHCA increases her insurance costs and lifts the mandate, she knows what she will do.

“I just won’t get insurance,” she said.

A likely beneficiary of the Republican plan would be Aaron Brust, 36, who started working at his father’s shoe store in Elk River six years ago when the housing market slowed and framing jobs disappeared.

Already benefiting from a subsidy that reduces his premium for an individual health plan, Brust would likely see costs go down. The Kaiser analysis predicts savings for younger, low-income workers under the AHCA’s age-based subsidies.

A disgruntled voter who wrote in “Judge Judy” on his presidential ballot, Brust said the extra money would help, given child support and other expenses. But he said it would feel odd if older, needier members of his community saw their costs go up or lost insurance altogether.

“That,” he said, “is pretty messed up.”