Sen. Rob Portman (R-Ohio). (John Minchillo/Associated Press)
Contributing columnist

Gary Abernathy is publisher and editor of the (Hillsboro, Ohio) Times-Gazette.

In small rural communities such as mine — places that largely supported Donald Trump for president but have higher-than-average uninsured populations — conflicting feelings about what to do about reforming health care run deep. There are divisions between health-care providers and the populations they serve, and divisions even within individuals themselves, as an inherent anti-government political bent collides with real-world struggles to pay for medical needs.

The Affordable Care Act has brought some undeniable benefits, especially for our local hospitals, by expanding Medicaid coverage and allowing more people to seek preventive care.

Even so, rising premiums and the fragile state of the insurance exchanges have people worried. They want to see Republicans follow through on their promise to repeal Obamacare, but questions about what comes next leave them anxious.

One real-world perspective comes from Highland District Hospital, a small facility in southern Ohio governed by rural township trustees, where officials are not at all torn. They cheered Ohio Gov. John Kasich’s decision to expand Medicaid in 2013, noting that the percentage of uninsured people here in Highland County was higher than the state average and that the costs of treating them were driving up costs for everyone else.

That opinion hasn’t changed much. Randy Lennartz, the hospital’s chief executive, told me that while Obamacare isn’t perfect, it did result in a wave of people seeking medical care who had previously ignored preventive-care visits. Those numbers have tailed off, but Lennartz said he believes that’s largely because their conditions were successfully treated.

The downside of Obamacare, he said, was that most people who signed up through the insurance exchanges chose the cheapest plans available, plans that came with deductibles in the $5,000-to-$10,000 range that few can afford. The median household income in Highland County is just under $40,000, according to census figures.

As in other states, insurance premiums rose under Obamacare, and choices continued to shrink. Just a few weeks ago, Anthem Blue Cross and Blue Shield announced it will not sell policies in Ohio in the Obamacare marketplace in 2018. On the heels of that announcement, Premier Health Plan said it is also pulling out, leaving as many as 20 Ohio counties with no health insurer on the state exchange.

It’s not surprising that some people look at this mess and say, “I told you so.” Still, Republicans in Congress find themselves in a dilemma. Obamacare is not working as advertised, but it works for some, even here.

(Jenny Starrs/The Washington Post)

With the opioid crisis in Ohio and other Midwestern states, GOP lawmakers such as my old boss, Sen. Rob Portman — a longtime proponent of recovery and “second chance” programs — aren’t comfortable with the reduction in Medicaid growth contained in the GOP health-care proposals.

But Portman is well aware of the 2016 presidential election returns from Ohio, and he likely wants to find a way to support a repeal-and-replace bill. Along those lines, Portman took the lead in promoting a separate $45 billion fund dedicated to opioid treatment that was added to the Senate bill, significantly increasing the chances of getting him to “yes.”

Passing a plan that hurts rural communities through Medicaid cutbacks is a risk. But for many GOP lawmakers, not repealing Obamacare is a bigger risk among voters in those same communities, where Trump reigns supreme and where people don’t look to the government to solve all their problems.

That there are such people is what a lot of folks in Washington have trouble understanding. The campaign by the Democrats and many in the media to save Obamacare relies largely on dire warnings about how many people will lose health-care coverage under the GOP plan. They wonder: How can Trump’s supporters stick with him when his proposals hurt them the most?

What they fail to grasp is that Trump’s supporters, by and large, are more dedicated to the principle of freedom from government mandates than they are worried about the loss of government subsidies or programs that social activists in Washington think they need.

Until Democrats can figure that out, their efforts to pry Trump’s supporters away from him — on health care or any other subject — will continue to be an endless source of frustration.