Republican governors, while remaining publicly committed to ending Obamacare, are telling their congressional delegations that repealing the health-care law without an adequate replacement would ravage budgets and swamp hospitals with the uninsured.

The leaders of states such as Ohio, Nevada, Idaho and even Alabama are urging a heavy dose of caution, according to statements and letters solicited by U.S. House Majority Leader Kevin McCarthy. They’re warning lawmakers as President-elect Donald Trump and congressional leaders come to grips with the reality of promises to end a law Trump styled “a disaster” even as it brought insurance to 20 million Americans.

“We must be careful not to increase the rate of uninsured, particularly for our most vulnerable citizens,” Utah Governor Gary Herbert wrote in his letter. “Reforms must be fiscally prudent but, should maintain or improve affordable access to health care for those that are currently covered.”

Herbert and eight other governors were in Washington today to talk behind closed doors with Senate Republicans in a meeting focused on changes to the joint state-federal Medicaid program, which the law greatly expanded.

“Nobody’s going to lose coverage,” Senator John Cornyn, a Texas Republican, said after the meeting. “If there’s one word that came up most, it’s flexibility. One-size-fits-all Washington doesn’t take into account the differences between a state like Texas with 28 million people and a state like South Dakota, for example.”

‘Won’t Lose Coverage’

Ohio Governor John Kasich also rushed to soothe those nervous they’ll be left on their own. “There’s some fundamental things we can do that will settle people down so they know they won’t lose coverage,” he told reporters after the meeting.

Governors like Kasich are on the front lines, facing the prospect of taking away coverage from 14 million people who enrolled in Medicaid in the 31 states that expanded eligibility. They also risk losing billions of federal assistance to sustain the program. Their worries are contained in letters to McCarthy from 26 states, including 16 led by Republicans, that were collected by Bloomberg News.

“We’re going to see what we can do to accommodate them.” Finance Committee Chairman Orrin Hatch, a Utah Republican who helped organize the meeting, said afterwards.

‘Must Be Careful’

If repeal disrupts insurance markets, state regulators would handle the fallout, and municipalities would bear costs when the uninsured show up in hospital emergency departments.

A million Ohioans gained coverage thanks to Obamacare and Kasich, in his letter, walked a narrow path between calling for its repeal and protecting what his state gained.

“We consistently opposed the ACA,” Kasich wrote to McCarthy. Nevertheless, the state is “concerned that a strategy to repeal now then later replace the ACA could have serious consequences.”

Trump and Republican leaders have given conflicting views on how to undo Obamacare, the departing president’s signature achievement. The law requires people to purchase policies and provides subsidies meant to make them affordable. Trump has said he wants to repeal the law and pass a new one that promises “insurance for everybody.” Neither he nor GOP leaders has revealed a replacement.

On the Precipice

Eighteen million people could lose insurance almost immediately if Obamacare is repealed without a replacement, the nonpartisan Congressional Budget Office said this week. While some Republicans in Congress attacked the report, Kasich’s letter ratified it. Repeal would “destabilize insurance markets and reverse recent coverage gains,” he said.

Repeal without replacement would add $15 billion in indigent-care costs and remove $3.5 billion from the coming budget, according to a report Jan. 11 by Policy Matters Ohio, a Cleveland nonprofit research organization.

In Alabama, Republican Robert Bentley — himself a dermatologist — is worried his state’s lone seller of Obamacare insurance may leave the market if the law is repealed, leaving 125,000 of his constituents without a way to get subsidized insurance.

“We must provide a smart and stable transition,” he wrote, “so consumers are not jeopardized and markets are not destabilized.

Repeal ACA

Other GOP-led states said little to defend the law. Arkansas, for instance, expanded Medicaid eligibility, helping almost halve the uninsured rate, while premiums in its ACA marketplace increased just 2 percent this year, a fraction of the national average. The state still wants out.

“Congress should repeal the ACA and return the power of regulating insurance to the states,” Governor Asa Hutchinson wrote.

In Kentucky, whose Obamacare program was hailed as a model in bringing care to a poor population, Republican Governor Matt Bevin said the law should be repealed “in its entirety.”

In his state, the uninsured rate has fallen by more than half in two years, to 6 percent in 2015.

Adaptation Strategy

At least three Republican-led states didn’t call for the ACA to be repealed: Michigan, Massachusetts and Nevada. Michigan Governor Rick Snyder, who has made a virtue of pragmatism, has been meeting with lawmakers and Trump’s team to discuss changes to the ACA, spokesman Ari Adler said.

“We took the idea of Medicaid expansion, made it our own, improved it and made it work better,” he said. Snyder didn’t formally respond to McCarthy’s request for input on how the law should be changed.

In Massachusetts, where then-governor Mitt Romney’s health-care overhaul became Obamacare’s inspiration, Republican Charles Baker touted bipartisan efforts to expand coverage. Nevada Republican Brian Sandoval said “my priority as governor was to make health care accessible and affordable.”

“You must ensure that individuals, families, children, aged, blind, disabled and mentally ill are not suddenly left without the care they need,” he wrote, noting a reduction in the state’s uninsured rate from 23 percent to 12 percent.

No Swift Change

New Mexico Republican governor Susana Martinez and the independently appointed insurance regulator are at odds. In response to requests by Bloomberg News, the governor sent a one-line statement calling for the law to be repealed. Insurance Superintendent John Franchini, in a letter to McCarthy, touted New Mexico’s lowered uninsured rate, and said the ACA added insurance options and improved hospital finances.

“We caution the new administration in making any swift changes,” he wrote.

Republican Governor Bruce Rauner of Illinois said Jan. 18 that he’s wary of repeal without a replacement, according to the Associated Press. Other Republican governors who have kept quiet include Larry Hogan of Maryland and Chris Christie of New Jersey.

Pressure is building on Republicans in a backlash similar to the 2009 protests that kick-started the Tea Party.

In Texas, House Ways and Means Committee chairman Kevin Brady held a meeting with constituents that was supposed to be about high costs and poor coverage under Obamacare. Instead, he was greeted by what the Houston Chronicle called a “skeptical and at times testy crowd.” Representative Cathy McMorris Rodgers of Washington had a Spokane event disrupted by protesters chanting “save our health care” and booing.

The ferment has made for some surprising stances.

Florida’s Rick Scott, a conservative stalwart, wrote that Obamacare was “devastating” and should be repealed on Trump’s first day. He also wrote that people should still be able to buy its insurance plans.

“Those with pre-existing conditions who may need or prefer Obamacare policies would be able to select this option,” he wrote.