There was a saying during the election that Donald Trump’s supporters were taking him seriously and not literally, while his detractors took him literally and not seriously. As the president-elect, many are starting to worry that neither camp got it right.

There’s still a lot, maybe even everything, up in the air when it comes to where Trump’s actual policies will land. As a candidate it often mattered much more what he did than what he said, since what he said was likely to change from one hour to the next. But as he starts to make nominations and choices for what his West Wing will look like, his policy focuses take a bit firmer shape. And one thing seems to be focusing itself: Healthcare is in trouble. And it’s going to endanger a lot of the folk who voted for Donald J. Trump.

It’s weird, right? A complete reversal from the candidate-Trump, who maintained that he wasn’t like the establishment Republicans; he wasn’t here to touch our entitlements, and was “not going to cut Medicare or Medicaid.”

“Every other Republican is going to cut, and even if they wouldn’t, they don’t know what to do because they don’t know where the money is. I do,” said Trump in a statement on his website in May 2015.

Only now—between the transition team’s man for Social Security, who’s a longtime advocate of privatization, and Paul Ryan’s forward propulsion on the subject—it seems like Trump is moving towards gutting Medicare, in favor of vouchers that can be applied to the purchase of private insurance.

A lot of this ties back into the Republicans’ distaste for the Affordable Care Act (ACA) and their argument that systems like it and Medicare are bad for the economy. But Paul Krugman argues in The New York Times that claim isn’t true at all:

People like Paul Ryan, the speaker of the House, have often managed to bamboozle the media into believing that their efforts to dismantle Medicare and other programs are driven by valid economic concerns. They aren’t.

It has been obvious for a long time that Medicare is actually more efficient than private insurance, mainly because it doesn’t spend large sums on overhead and marketing, and, of course, it needn’t make room for profits.

What’s not widely known is that the cost-saving measures included in the Affordable Care Act, a.k.a. Obamacare, have been remarkably successful in their efforts to “bend the curve” — to rein in the long-term rise in Medicare expenses. In fact, since 2010 Medicare outlays per beneficiary have risen only 1.4 percent a year, less than the inflation rate. This success is one main reason long-term budget projections have dramatically improved.

But even if the research on the fact that health care inflation is reaching historic lows were off, there seems to be a compelling case for Trump to find some solace in Medicare: It’s where a lot of his voting base is.

Photo Credit: Gage Skidmore cc
Photo Credit: Gage Skidmore cc

Popular vote or no, the Republican candidate tapped into a voter base that even polling wasn’t able to reach. Whatever else you make of the millions who voted for him, his base is overwhelmingly white, bringing home 58 percent of white voters. 62 percent of the small city or rural voters also went for him.

It’s a group that strongly resembles the average Medicare user, which is 76 percent white nationwide. The uninsured have dropped to a new low of just about 10 percent after the introduction of the ACA, and as The Washington Post writes that effect is more pronounced amongst poor whites:

Gallup-Healthways tells me that among whites without a college degree who have household incomes of under $36,000, the uninsured rate has dropped from 25 percent in 2013 to 15 percent now — a drop of 10 percentage points. It’s often noted that the law has disproportionately expanded coverage among African Americans and Latinos. That is correct, but it has also disproportionately expanded coverage among poor white people.

Now, it’s hard to know how many people we’re talking about here. But other evidence supports the idea that a lot of red state voters have gained coverage from the law. In some parts of rural Kentucky, the Medicaid expansion has greatly expanded coverage. And CBS News recently reported that even some Republican officials in the GOP-led states that expanded Medicaid are not prepared to see that evaporate. Gallup-Healthways numbers also show that the drop in the uninsured rate has outpaced the national average in some red states that have expanded Medicaid, like Kentucky, Arkansas, and West Virginia.

It’s counterintuitive but it seems to fit into exactly what a lot of the election post-mortem has found: Republicans spoke to the economic struggles of the white working class better than the Democrats did. But the Republican’s talk of cutting healthcare seems to go against what much of the base wanted. The New York Times captured it best the week of the election with one Trump supporter who hoped there wouldn’t be an ACA walkback because her daughter had obtained subsidized insurance coverage for only $50 per month. “I think he was bluffing,” she told The New York Times “with a frown.”

Unfortunately for her, while the path may be a bit fraught with challenges, the tools appear to be in place for the Republicans to proceed if they choose to. For most folks who would be affected by this it would mean staying on health insurance by getting or remaining with a job that includes it, which might entail getting more education.

It’s possible, however, that Trump goes the other way on this. There will probably be a fight of some sort for Medicare (and maybe the ACA, depending on how Trump lives up to his recent healthcare sentiments), but Trump—perhaps more than anything—is seen as an opportunist. He’s skilled at playing the media, and he knows when coverage and battles are no longer worth his limelight. Often his speeches come off as two-faced, but many argue he goes where his supporters are. 78 percent of people who said their family financial situation is worse off today stood for him. Maybe he’ll return the favor.