With the latest Republican health care overhaul teetering near collapse, one group in particular is watching with heightened anxiety.
The debate in Congress is personal for many of those who gained coverage through Medicaid in the 31 states that expanded the program under former President Barack Obama's Affordable Care Act.
Alan Purser, who lives in eastern Arkansas, credits expanded Medicaid with saving his life, after a routine doctor's visit ended with him being hospitalized and treated for multiple blood clots in both lungs. The 60-year-old diabetic said he would not be able to afford his insulin medication because he does not qualify for traditional Medicaid.
"I am going to be up a creek if it goes through," he said.
The Medicaid expansion brought health insurance to some 11 million lower-income Americans, helping drive the nation's uninsured rate to just 9 percent. That program would have ended in three years under the initial version of the Republican's latest health care bill, triggering widespread uncertainty for both recipients and states facing the prospect of winding down their coverage.
The latest GOP effort appeared to be doomed late Monday when Republican Sen. Susan Collins of Maine announced her opposition, citing in part the proposed cuts to Medicaid that she described as "devastating." With Democrats united in opposition, the only way Republicans can revive the bill is to alter it in ways they hope will change opposing senators' minds.
States signed up for the Medicaid expansion under the promise that the federal government would pick up the vast majority of the costs. Experts and officials in several of the states that opted for it said that under the GOP plan they would not have the ability to cover the costs of all those who benefited.
"I don't want to have to look those people in the eye and say you are losing your health insurance," said Nevada state Assemblyman Michael Sprinkle, a Democrat.
In his state, more than 300,000 people gained health insurance through the expansion, which extended coverage to more lower-income Americans by raising the income limit. Most were adults with no children at home.
Kentucky was another state seeing big gains under Obama's health care law, its uninsured rate dropping from 14.3 percent before it took effect to 5.1 percent last year. The 64 percent decline was the largest of any state, according to data from the U.S. Census Bureau.
Nearly all that gain was because Kentucky's former Democratic governor opted to expand Medicaid, which provided coverage to 461,000 Kentuckians. The state also is home to Senate Majority Leader Mitch McConnell, who is among those leading the Republican effort to dismantle the law, and now has a Republican governor who also favors repeal.
John Holbrook, of Ashland, does not want to see the law repealed. He received substance abuse treatment under the Medicaid expansion, after being hospitalized with a dangerously high blood-alcohol level in December 2015.
"I would be dead or still homeless," said Holbrook, 36, who now works as a peer support specialist at a private treatment facility that accepts Medicaid. "Working in recovery, I see it changing lives every day."
The original version of the GOP bill would end funding for expansion enrollees in 2020, among other changes that would shift more of the financial responsibility of the $500 billion-plus overall Medicaid program to the states. States already spend, on average, about 25 percent of their budgets on Medicaid.
Republicans have long sought to rework the program in an effort to rein in federal spending. But cutting the program and shifting more responsibility away from the federal government creates tricky math for the states.
In California, 3.8 million residents gained health coverage under the expansion, and a third of the state's population is enrolled in Medicaid. Given that, there is little chance the state program would be able to exist in its current form under the GOP plan.
A state analysis of a similar GOP proposal found that California would be on the hook for an additional $30 billion a year starting a decade from now, and that didn't factor in the total elimination of federal funding for the expansion population.
"We can't come up with that kind of money," said Phil Ting, a Democrat who is chairman of the budget committee in the state Assembly. "It's like picking and choosing between your thumb and your pinky, what we could protect."
Under the Republican bill, all the federal money currently being spent in various states on expansion would be collected, beginning in 2020, into a single pool. It would include other funding that is being used for subsidies that have helped an additional 12 million people buy private health insurance through government-sponsored markets.
That money would then be shared among all states based partly on how many lower-income adults they have. Under the initial version of the bill, that additional money would stop entirely in 2027.
Stephanie McCoin of Baton Rouge, Louisiana, fears her 27-year-old daughter will be among those hurt by efforts to undo the Medicaid expansion. She has a chronic adrenal condition, and at one point before the Affordable Care Act went to emergency rooms eight times in a little over a month because she couldn't afford insurance.
"I'm afraid that if she loses this," McCoin said, "she will die."