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Maribeth Coote says she hates Obamacare, but it’s the only health coverage option she can afford in this remote, hardscrabble corner of southwestern Pennsylvania.

The government should “just back off and let me figure it out, and get out of the whole industry” of health care, the 52-year-old Chicago transplant to the tiny town of Rogersville said as she cleaned up her woodworking shed from recent flooding.

Donna Himelrick is uninsured and priced out of the market, despite being the mayor of Hundred, a small town 20 miles (32 kilometers) south in neighboring West Virginia.

“I make too much for Medicaid and not enough that we can afford insurance. It’s a difficult situation,” Himelrick, 62, said at a clinic in nearby Burton, where she pays for medical treatment in cash, according to what she can afford.

Like millions in Appalachia, both women voted for Donald Trump in last November’s election seeking to upend the political system. The Affordable Care Act, they insist, is not the answer to their health woes.

But both would face dramatic changes to their health care — probably for the worse, at least at first — if Obamacare is replaced by the plan being hashed out by Republican lawmakers in Washington, a cultural and political world away.

Local clinics are a lifeline for many in this economically stagnant, overwhelmingly white region. Ambulance coverage is spotty, and rough roads with rougher weather can leave insular communities even more isolated in emergencies.

Now that Trump is president, the reforms installed by his predecessor Barack Obama are under threat, potentially spelling disaster for several community health centers in Pennsylvania and neighboring West Virginia.

“There are a lot of things that need to be straightened out” with health care, but shuttering local clinics “would be a concern to me,” Himelrick conceded. Lawmakers should “tread lightly.”

The Cornerstone Care CHC in Rogersville, which treats Coote, and several other facilities serve an area where coal mines have recently closed, pushing up unemployment, and where health facilities can be 20 miles or more apart.

“We are the safety net for this community,” Janice Morris, chief executive of the Clay-Battelle CHC in Blacksville, West Virginia, said in an interview.

Under Obamacare, several states have expanded Medicaid, the federal health program for the poor and disabled, to include residents whose income is at or below 138 percent of the poverty level.

But with some 670,000 people in Pennsylvania and 175,000 in West Virginia eligible for Medicaid through the expansion, a rollback of the program as proposed in the Republican plan would “have a terrible impact there,” Senator Bob Casey, a Democrat from Pennsylvania, told AFP back in Washington.

At Clay-Battelle clinic, nearly half of the patients are either on Medicaid or Medicare, the coverage program for the elderly.

Many of the clinic’s 300 to 400 weekly patients pay on a scale according to their financial ability — a system known as “the slide.”

The clinic covers the slack through Medicaid and commercial insurance reimbursements, federal and state funding, and grants.

Obamacare has helped Clay-Battelle and Cornerstone lower the rate of uninsured who get treatment there. The resulting increase in reimbursements have translated into expanding staff and hours of operation.

That could crumble if Obamacare disappears.

“A lot of people don’t recognize that the health coverage they have was made possible through the Affordable Care Act,” Morris said.

Don Humbertson, 64, says he owes his life to Clay-Battell doctors who discovered he had lung cancer.

The retired concrete worker is insured through his wife’s bus-driver job, but he has grown to appreciate how Obamacare has given those in need a chance.

“Obamacare when it first came out, I was totally against it,” said Humbertson, who has had difficulty breathing and speaking since part of his right lung was removed.

“But I’ve seen how it was helping some people.”

Instead of pulling it out by its roots, he said, Republicans and Democrats should come together and fix the current law.

That is not what’s happening.

Republican leaders are keen to keep popular provisions that bar companies from refusing to insure people because of pre-existing conditions.

But in a bid to provide more free-market choice and competition, they want to slash the amount of subsidies that would be provided for Americans to buy health care, potentially putting insurance out of reach for millions.

The bill is hanging by a thread, with the House of Representatives likely to vote on the measure Friday.

“We feel like we’re just getting whipsawed around,” Cornerstone Care chief executive Richard Rinehart said.

“We’re in the trenches, we’re dealing with these health issues that are real.”

Cornerstone operates another clinic in the larger town of Waynesburg, where coal silos, conveyors and green buildings of the shuttered Emerald Mine stand as ghostly reminders of better days.

In Trump country, many health workers are aware of the irony of a Republican law appearing likely to hurt health centers’ ability to care for the very people who voted the president into office.

“I see it very personally,” Morris said. “Many of our staff people are Trump supporters.”

But health outcomes of Americans are “at risk” because of the Republican plan, he added.

“I would urge them to really think about those people in rural America that they got support from… Don’t turn your back on them.”

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