Rob Krupicka served nine years on the city council in Alexandria and three years in the House of Delegates before he was diagnosed with bipolar II disorder in 2016.

“I handled not being treated modestly well,” Krupicka said. “I’m handling being treated really well. It’s a dramatic difference in my life. I’m more productive. I’m a better father. Lots of things are better about my general day-to-day life.”

The small-business owner, a Democrat who did not seek re-election to the House in 2016, doggedly manages his mental illness with medicine, semiannual checkups with a psychiatrist and appointments with a therapist — all with the help of his health insurance coverage.

But Krupicka’s future health coverage — and that of millions of other Americans with “pre-existing conditions” — hangs in the balance as the Senate prepares to consider a bill the House of Representatives passed last week. It would scrap elements of the Affordable Care Act championed by then-President Barack Obama and replace them with the Republican-drafted American Health Care Act.

Fear, or hype?

“It’s designed to take health care from a lot of people in order to reduce premiums for some Americans and give tax breaks to some other Americans,” Krupicka said, echoing the outpouring of criticism from Democrats and advocates who say the legislation could hurt those already struggling with health issues. “It puts a large number of Americans on the health care chopping block.”

Republicans defended the vote as an initial step toward keeping their oft-repeated campaign promise to replace Obamacare and reduce government’s role in health insurance markets. Rep. Dave Brat, R-7th, one of six Virginia Republicans who voted for the House bill, said the anxiety about coverage for those with pre-existing conditions is a product of political “hype.”

“It explicitly says in there states may not opt out of the pre-existing condition regulations,” Brat said in an interview Friday. “Truth is a casualty of D.C. politics.”

The four Democrats in Virginia’s U.S. House delegation and one Republican — Rep. Barbara J. Comstock, R-10th — voted against the bill.

Though the bill is expected to face significant revisions in the coming weeks as it heads to the Senate, the version that passed the House would limit Medicaid spending and allow states to seek federal waivers to shape insurance coverage requirements within their borders.

The apparent loosening of requirements forcing insurers to cover people with pre-existing illnesses has stoked fears that some states will let insurers charge those patients more if their coverage has lapsed. States would have to set up high-risk pools to help those people afford coverage, though those arrangements have not proved reliable in the past. In some cases, high-risk pools have become too expensive to run because patients who are already sick typically require more expensive care, and in others, it took years for patients to get into the pools in the first place.

Sounding the alarm in drastic terms, Gov. Terry McAuliffe, a Democrat, said in a CNN interview Thursday morning that “people will die” if the bill passes the Senate and President Donald Trump signs it into law.

Brat said the Democratic focus on coverage obscures the problems of rising costs and insurers abandoning Obamacare markets, including Aetna’s announcement Wednesday that it will stop selling such plans in Virginia next year over projected losses.

“I can see why the governor would rather jump up and down and do drama rather than have to face those facts,” Brat said. “Because they slap you upside the face.”

Trump himself has pointed to Aetna’s Virginia decision while making the case for the bill. “Death spiral!” he said in a Thursday morning tweet that linked to news coverage of Aetna’s move.

Physicians, advocates

Concerns about the bill were broad and blunt, coming from physicians, advocates for people with mental illness and disabilities, Virginia’s influential hospital association, and Democratic candidates running to succeed McAuliffe in Virginia’s gubernatorial race.

“In terms of morality and humanity, I think it’s a thoughtless, inhumane act,” said Dr. Martin Buxton, chief of psychiatry at CJW Medical Center and medical director at Tucker Pavilion. “The people who need the most help and the most access will not get it, and it’s going to drive up costs because those who pay for insurance and pay for care are going to have to pay more to cover those who don’t.”

In its current form, the bill likely would harm people in poverty and those with mental illness the most, Buxton said.

In a prepared statement, a spokesman for the Virginia Hospital & Healthcare Association said the group is “extremely concerned about the potential negative impact the just-passed (AHCA) will have on Virginia’s hospitals, our patients, and the communities we serve.”

Many health policy experts and analysts believe hospital costs would soar with the passage of the AHCA, largely because it does not roll back the cuts the Affordable Care Act made to Medicare reimbursement rates, but it is expected to increase the number of uninsured people in the country.

Hospitals are required to care for anyone who comes into their emergency departments, regardless of whether they can pay for it.

Uncertainty about cuts

When the Congressional Budget Office weighed in on the first iteration of the AHCA in March, it estimated that the bill, if passed, would increase the number of uninsured people in the U.S. by 14 million in 2018, rising to 21 million in 2020 and 24 million in 2026.

People with disabilities also stand to lose access to necessary services because of the bill, advocates said last week. The Arc of Virginia said that nationwide the bill would result in more than $880 billion of Medicaid funding cuts over the next decade.

“Many of the individuals receiving Medicaid-funded community services require assistance with bathing, feeding, toileting and dressing,” Kim Goodloe, president of the Arc of Virginia, wrote in a letter to Virginia’s congressional delegation. “If these Virginians were unable to access services that are currently provided through the Medicaid program, they would likely face homelessness or costly and unnecessary institutionalization. Thanks to Medicaid, they can remain with their families and in the community instead.”

The Virginia Department of Health could stand to lose millions in federal grants, as the AHCA includes severe cuts to the Centers for Disease Control and Prevention.

Some of those grants have existed for more than a decade, but were wrapped up in the CDC’s Prevention and Public Health Fund following the passage of the Affordable Care Act.

The grants pay for a slew of public health programs, from immunizations to heart disease and stroke prevention.

But whether the state’s public health infrastructure would sustain such cuts is up in the air, as the AHCA is still expected to undergo changes and the Congressional Budget Office has yet to weigh in on its cost.

“We don’t know all the details yet since the process is still unfolding,” said Dr. Marissa J. Levine, Virginia’s health commissioner.

U.S. Sens. Mark R. Warner and Tim Kaine, both Democrats, have said they will not support a bill that would cause some to lose health coverage.

Candidates for governor

With the governor’s race in full swing and the growing possibility that the state’s next chief executive could face important decisions on coverage policies, Democratic candidates seized the opportunity to blast their GOP rivals.

Former congressman Tom Perriello went viral Thursday with a health care-themed ad showing an ambulance being flattened by a junkyard crusher, a visual Perriello said represents what Republican leaders want to do to “affordable health care.” The ad, shot in one take with an engineless ambulance, had more than 340,000 views on YouTube as of Saturday afternoon, more than 15 times the views of Perriello’s first TV ad spotlighting his alliance with Obama.

Perriello and his opponent in the June 13 Democratic primary, Lt. Gov. Ralph S. Northam, scheduled campaign events Friday focused on health care. Both men denounced the GOP bill’s passage during a debate Thursday night in Roanoke.

“This is the most spineless, unprincipled cruelty that I have ever seen come from a legislative body,” Northam said in a statement after the House vote.

Ed Gillespie, the Republican front-runner in the Virginia governor’s race, voiced measured support for the bill, but said he would review it to “assess its potential impact on Virginia” and watch as the Senate makes changes.

“The House today took an important first step toward repealing the disastrous Obamacare bill, which Ralph Northam and Tom Perriello want to keep, that has driven up premiums, caused us to lose our choice in doctors, and driven insurers like Aetna out of the Virginia market,” Gillespie, a former Republican National Committee chairman and political consultant, said in a statement.

State Sen. Frank W. Wagner, a Virginia Beach Republican also seeking the GOP nomination for governor June 13, struck a similar note, saying the existing law was “falling apart under its own weight” and “something had to be done.”

“Some of the things I’ve heard about sound great,” Wagner said. “Some of them I’ve got a few questions about.”

Corey Stewart, the Prince William Board of County Supervisors chairman and the third Republican gubernatorial candidate, said in a written statement: “As long as the federal government has its hands all over our health care system it will never work, which is why I’ve always supported the full repeal of Obamacare and returning control of health care to the local level by block granting Medicaid to the states.”

Virginia is among the 19 states that chose not to expand Medicaid under the Affordable Care Act. For years, McAuliffe has pleaded the case with Republican General Assembly leaders, saying expansion would allow the state to cover more low-income people with more federal dollars. Arguing expansion could be fiscally ruinous, Republican leaders haven’t budged, but they’ve raised concerns that the Republican bill’s per-capita cap on Medicaid funding could hurt states that chose not to expand the program.

“Ultimately, I would like to see Congress pass a bill that gives flexibility to the states to lower premiums provide better quality coverage,” House of Delegates Speaker William J. Howell, R-Stafford, said in a statement. “Most importantly, we need to make sure this legislation does not punish Virginia for being a fiscally responsible state and for not expanding Medicaid.”

Krupicka, the former Alexandria delegate, said he has had a hard enough time trying to find mental health professionals who can treat his bipolar disorder and meet his insurance company’s requirements.

“I think a lot of this comes down to the basic question for our country,” Krupicka said. “Whether we think all Americans deserve access to health care and insurance or we think only people we choose should have access to health care and insurance. Those are very different views of this country.”

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The Associated Press contributed information to this report.

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