Patients receive free osteopathic treatments at a health clinic on July 22, 2017 in Wise. Hundreds of Appalachia residents received free medical, dental and vision services at the Remote Area Medical (RAM), clinic held annually at the Wise County Fairgrounds in western Virginia. The county is one of the poorest in the state, with a high number of unemployed and underinsured residents. (Photo by John Moore/Getty Images)

A majority of the roughly 280,000 people who now have health care under Virginia’s expansion of Medicaid live in localities won by President Donald Trump, who campaigned on eliminating federal funding for expansion by repealing the Affordable Care Act.

In 60 cities and counties, more than five percent of the population has gained health coverage under the expanded program, which began enrolling new patients in November. Trump won a majority of the votes in all but 18 of those localities, according to enrollment figures provided by the state, population estimates and election results.

Statewide, 142,230 people living in cities and counties won by Trump have enrolled, compared to 137,259 people living in localities won by Hillary Clinton.

“There’s this image of Medicaid as a program that is primarily of benefit to the inner cities, but the reality in Virginia and many other places is that large numbers of people living in rural communities lack health care,” said Stephen Farnsworth, a political science professor at the University of Mary Washington. “Medicaid expansion is extraordinarily beneficial for people living in those counties that supported Trump.”

The outcome is not necessarily unexpected. Farnsworth and two other political scientists who analyzed Medicaid enrollment data predicted Republican districts would be among the biggest beneficiaries of expansion in 2014, well ahead of the bitter fight among Virginia Republicans last year, which saw a handful of GOP lawmakers partner with Democrats to pass the measure. The move provides health coverage to individuals making up to about $17,000 or a family of three making up to about $29,500.

The battle lines were particularly stark in the Republican stronghold of Southwest Virginia, which as a region has seen some of the highest rates of enrollment, with as many as eight percent of residents in some localities now covered under the program.

Del. Terry Kilgore, R-Scott, was among the first to publicly support expansion on the condition that work and job training requirements were attached. Some of his fellow representatives from the area joined him. Others, like outgoing Sen. Bill Carrico, R-Grayson, remain opposed.

“I still don’t think this was the right thing to do,” he said, citing uncertainty about how much the program would ultimately cost the state and what will happen if the federal government reduces funding in the future.

“All these people that we’re looking at enrolling now, what are we going to do? Are we going to drop them when we find out we can’t afford it?” he said in an interview last week. “That’s going to be more detrimental to them.”

Health care providers in the region disagreed that it would be worse for residents to have insurance even briefly than to have never had it at all.

“People need to come here and see what we’re seeing in Southwest Virginia,” said Teresa Gardner Tyson, the executive director of Health Wagon, a free clinic based in Wise County. “People are dying. You would be thankful for any day that someone has health insurance.”

She attributed the apparent conflict between the politics of the region and the degree to which the population has benefited from Medicaid expansion to tradition and support for the region’s struggling coal industry, of which Trump was a vocal supporter.

“I know, on the granular level, you do have patients that really needed the expanded Medicaid access and they may have voted for Trump, but I think it comes back to loyalty for the coal industry,” she said.

In 2017, the Kaiser Family Foundation conducted focus groups with Trump voters who have health coverage through the Affordable Care Act. They found that people who gained access to Medicaid in states that expanded coverage were highly satisfied with their insurance, but most didn’t realize they were accepted as a result of the Affordable Care Act.

In Wise, Connie Little, the Medicaid enrollment coordinator at Health Wagon, said politics don’t usually come up when she’s talking to people about the program.

“Honestly, I don’t think it’s much of a concern,” she said. “I’ve had patients who say, ‘Well, I’m so thankful for Trump (that I was able to get insurance),’ and I stop them and say, ‘Well, it was actually our state that brought the expansion.’”