In the 20 years Matt Ruby has been a commercial fisherman, he couldn't afford health insurance and didn't have a primary doctor. After the Affordable Care Act passed, Ruby had his first blood test in decades.

Now, on the cusp of the biggest health care overhaul since 2013, Ruby worries.

"I will have to cancel insurance,” he said. “I don’t want to, but I won’t have any other choice.”

Much about the new Republican bill, called the American Health Care Act, is uncertain. Republicans hope to send the measure to the Senate by the end of this month, but even many conservatives have come out against it. Physician and hospital groups also disapprove.

The bill could be on President Donald Trump’s desk before the recess in mid-April. Robert Hartwig, an economist at the University of South Carolina and an insurance expert, said the politics of the last year have shown the country is ready for change.

"The political winds that blew Mr. Trump into office … suggested that people thought that there was too much intrusion in health care and it cost too much," he said.

Ruby, a 44-year-old James Island resident, said he doesn't care about Democrats or Republicans, but he finds the new administration "shocking." Middle-aged and self-employed, he's one of the South Carolinians most likely to be affected by the new legislation. Here's what we know, and don't know, about how the bill will affect Ruby and his family.

Will Ruby have to buy insurance?

The Affordable Care Act fined people for not being insured, never a popular part of that law. The Republican bill does away with that requirement. Instead, the new law would make it harder to come back if you drop coverage.

For example, if Ruby dropped his insurance but needed it again after an injury at his high-risk job, he would have to pay 30 percent more on his premiums for a full year.

Proponents say this gives Americans the freedom to opt out of insurance if they want to, while still encouraging especially younger people to keep their coverage.

Opponents criticize this part of the plan because uninsured people may not be willing to pay the year-long charge to re-enter the market unless they are sick and need insurance badly.

A Standard & Poor's analysis estimated 6 million to 10 million Americans would fall out of coverage under this plan. Some estimates, like one from the Brookings Institute, put that number closer to 15 million.

"There's no way that it would end up with people having more, better coverage in the way the president said," Shelli Quenga, director of programs for the Palmetto Project, an agency that helps people sign up for insurance, said.

Ruby said though he is healthy, he would have bought coverage in his younger years if he could have. He knows in order to drive costs down for everyone, healthy people have to sign up for insurance.

"I would have had no problem paying it forward," he said.

How will Ruby's age and income affect his costs?

Ruby will likely see his premiums increase if he decides to keep his coverage. Right now, Obamacare's subsidies, which 85 percent of people buying on the individual market receive, give him about $4,300 off his premiums annually. That's based on his income level — about $20,000 per year. Ruby pays about $485 total per year under his current health insurance.

The Republican plan would disregard Ruby's income and instead give him a tax credit of $3,000 based on his age. The older you are, the greater the tax credit.

Republican plan's tax credits, by age bracket
  • $2,000 age 30 or younger
  • $2,500 age between 30 and 40
  • $3,000 age between 40 and 50
  • $3,500 age between 50 and 60
  • $4,000 if you are 60 or older

Based on age, the bill also allows companies to charge older people five times what they charge younger people. Obamacare capped the ratio at three-to-one.

Standard & Poor’s estimated, working with 2016 data, the plan would bring average premiums for a 21-year-old down from $3,281 to $2,625. For a 64-year-old, they estimated annual premiums would rise from $9,844 to $13,125. Ruby falls somewhere in-between.

As a result, fewer older people will enroll, but insurers will improve their profits, Standard & Poor’s reported.

A Standard & Poor's report released Tuesday predicted the Republican's new tax credit system could hurt states with higher than average premiums. Those states with the highest monthly premiums are most likely to have higher rates of people without insurance, under the new plan. Based on 2013 numbers from the Kaiser Family Foundation, South Carolina's premiums are slightly below average. The South Atlantic region as a whole is also a hair below the national average.

What kind of choices will Ruby have?

Insurers could again begin offering cheaper plans that offer less coverage if Republicans are successful. The Affordable Care Act required every insurer to guarantee 10 essential health benefits. Those include emergency services, hospitalization and prescriptions, among other services. The idea was to protect Americans from low-grade plans that did not cover these benefits. Because of the type of legislation it is, the bill being debated now cannot touch this provision. But the minimum benefits could be removed in other ways in the future.

Insurance plans would have more flexibility. Ruby could soon purchase something cheaper, and he said he would consider doing so if it were cost-effective.

Hartwig said he thinks this plan will encourage people to shop more for their plans. Consumers would have to be wary of plans that may be cheaper but don't offer complete coverage.

"Whether you voted red or blue, people are going to find themselves with more personal responsibility," he said.

How will Ruby's family be affected?

Ruby's partner, Eileen Dougherty, had a double lung transplant in 2013, so she has high bills and a pre-existing condition. The couple also has two teenage daughters.

The Republican bill keeps two of the most popular provisions of the Affordable Care Act that are important for Ruby's family: Insurers cannot deny her coverage, and Ruby’s daughters can stay on their parents' health insurance until they are 26.

How will people poorer than Ruby be affected?

In 2020 South Carolina's Medicaid will change to a per capita system.

In the Palmetto State, Medicaid costs about $7 billion a year and covers almost 1 million people, most of them children. The federal government pays for most Medicaid costs in the state. The proposal would set a federal spending cap per Medicaid beneficiary, but it is unclear how funding for the program in South Carolina would fluctuate if the replacement bill is passed.

A big difference for South Carolina is the responsibility of managing Medicaid will be shifted to states, Quenga said. Scaling-back Medicaid will hurt rural and poor states, such as South Carolina, she said. The Palmetto Project is most worried about the bill's effect on Medicaid recipients.

Giving more responsibility to states may help maximize the health care dollar, Hartwig said. States will design their own programs, some of which Hartwig said will fail. He likened it to having 50 different experiments at once.

"Now legislatures are going to be held accountable for the availability and cost of health care," he said.

What about everyone else?

Ted Pitts, CEO of the S.C. Chamber of Commerce, said he thinks opening health insurance markets to greater competition would have benefits for the state’s businesses.

"The business community appreciates the efforts of leadership in D.C. to address the issues," he said.

Frank Knapp, president and CEO of the S.C. Small Business Chamber of Commerce, pointed to the stress the bill could place on the state's rural areas. Rural hospitals are often the largest employer in such communities, he said, and now he expects less money will be going into the already-struggling spaces.

Knapp said his greatest concern is the health of the small business workforce. Undermining the ability of those employees to buy their own insurance will undercut small businesses, he said.

"This is not about a better plan," Knapp said. "This plan is about controlling federal expenses."

The majority of workers who get their insurance through their employer would see little change under this plan, Hartwig said. The debate surrounds those South Carolinians, like Ruby, who buy private insurance, he said.

What's next for the bill?

The bill now has to get the seal of approval from the House Budget Committee before it can get to the House floor. 

Speaker of the House Paul Ryan, R-Wis., has discussed a three-pronged plan. This bill is the first of those three steps. The second step will be removing many of Obamacare's regulations. Then Republicans plan to introduce new legislation.

Ruby said that while he doesn't feel low-income, he doesn't have the ability to pay much higher premiums than he is today. Quenga said she is concerned about the effects of the bill but wants to hear legislators hash out the particulars.

"We would appreciate the opportunity to hear our elected officials debate this," she said.

Emma Dumain contributed to this report from Washington, D.C.

Reach Mary Katherine Wildeman at 843-937-5594. Follow her on Twitter @mkwildeman.