After Teal Kinamun fell down a flight of stairs while carrying a bookcase, she ended up in the emergency room with a broken back — and no health care insurance.

"They said, 'Let's get you signed up for the Oregon Health Plan,'" she recalled. "It made all the difference in the world to have that."

Kinamun was back to work after receiving care and recuperating for two months in bed.

Although she has a job as an elementary school instructional assistant, Kinamun has a low enough income that she qualified for OHP coverage thanks to expanded eligibility from the 2010 Affordable Care Act, also known as Obamacare. The federal government and states that expanded coverage provide government-subsidized health insurance to low income Americans.

Efforts by Republicans in Congress and President Donald Trump to repeal and replace the Affordable Care Act have the Talent resident deeply worried. The replacement American Health Care Act now being debated in Congress would provide tax credits for people to buy health insurance.

Up to 20 million Americans could lose health insurance coverage, according to some preliminary estimates.

"I'm horrified," Kinamun said. "I'm not sure people will actually have medical care under this proposal. It's worrisome. It's not just about my personal story — 20 million other people could be impacted."

In Jackson County, 25,173 residents received OHP coverage because of expanded eligibility from Obamacare. The expansion pushed the number of county residents on OHP past 63,000 people — or almost one in three residents.

Statewide, rural areas, including Southern Oregon, saw the most coverage gains, while the Portland area saw the least. More than 1.1 million state residents — or one in four Oregonians — now have subsidized insurance after approximately 400,000 gained coverage.

The Republican plan would cut federal payments for that expanded care after 2020.

Critics of Obamacare say America has added an expensive new entitlement that is unaffordable, especially when the deficit-ridden federal government already can't meet its obligations to provide Social Security retirement benefits and Medicare health insurance coverage for future retirees.

Oregon is facing a $900 million budget hole because of the health care expansion and changing federal payments, even as the federal government continues to pick up most of the tab for Obamacare.

The Affordable Care Act did little to restrain the rising cost of health insurance for people with subsidized, employer-provided or individually purchased insurance.  And prescription drug prices continue to skyrocket as companies corner the market on existing medicines and raise prices, and introduce new specialty drugs that cost tens to hundreds of thousands of dollars.

Not enough young, healthy people signed up for Obamacare, and many who did join were sicker and had ailments that had been left untreated.

The Republican plan would keep some of the more popular elements of Obamacare, including protections for people with pre-existing conditions. Parents could still keep their children on their insurance plans until age 26.

Steve Krook of Central Point, who was recently visiting a medical clinic, said Obamacare should be repealed and replaced.

"I think it's a great idea," he said. "They have to do something. Costs are going through the roof. I do agree with repeal and replace. It will collapse on its own without it."

Krook said he buys health insurance as part of an employer-provided retirement benefit and likely couldn't afford insurance on his own.

"Out in the real world, it's expensive," he said.

Providers worry about coverage

Providers at La Clinica, which runs community and school-based health and dental clinics in the Rogue Valley, saw first-hand many of the changes brought by Obamacare. The organization serves everyone, but tends to attract low-income and uninsured patients because of its focus on affordability.

Chief Executive Officer Brenda Johnson said La Clinica was able to expand its clinics, hire more workers and help meet a backlog of untreated medical problems in the community.

"Many patients had delayed treatment," she said. "They needed dental cleanings and care. They had put off their own diabetic management. Many had really struggled to maintain the primary care support most people take for granted. We wish we could have seen them earlier in their disease state."

Johnson said she is most concerned about proposals to scale back Medicaid funding that allowed more people to enroll in OHP.

"Oregon benefited greatly because the Affordable Care Act provided coverage for many people who had gone without," she said. "Locally, thousands and thousands could go without coverage. I can't imagine a situation where our communities or our country would be OK with that."

In the past, 53 percent of La Clinica's patients were uninsured. Last year, that number was cut to 30 percent uninsured, said La Clinica Development Officer Maria Underwood.

When patients have insurance, they are able to access the full range of medical tools, including prescription drugs, specialist visits, diagnostic exams, hospital care and mental health and dental care, she said.

"The most striking thing we saw was people who had never been to the dentist in their adult lives," Underwood said. "They were finally able to catch up on dental care. We are doing a lot of restorative and rehabilitative care. Many had gone without medical care. There were people who had not received recommended vaccinations or screenings. Many had endured years and years of chronic pain and didn't have the resources to come and get things checked out."

After she went through a divorce, Phoenix resident Marsa Morse said she spent years as a single working mother without health insurance for herself or her daughters. She vividly recalls standing helplessly by when one of her daughters had scarlet fever. Antibiotics can prevent complications of the disease, which can include kidney disease, heart disease and arthritis.

"If I'd had the money, we would have gone straight to the doctor, but we couldn't," Morse said.

Her daughters are now grown, and after passage of the Affordable Care Act, Morse was able to get OHP coverage. She is trying to catch up on years of neglected health problems, including spinal arthritis, that she believes worsened due to lack of medical care. Steroid injections in her back and hips allow her to walk with less pain.

"If I'd have had insurance when I was raising my kids, I would have been in better health and could have worked more," Morse said.

Now 66 years old, Morse recently qualified for Medicare for older Americans, but remains worried about low income children and adults who receive Medicaid coverage due to Obamacare expansions.

"I'm terrified for them," she said.

Economic impacts

In Jackson County, residents eligible for OHP sign up through the local coordinated care organizations AllCare Health or Jackson Care Connect. CCOs are tasked by the state to integrate physical, mental and dental care while also holding cost growth to 3.4 percent annually.

AllCare Vice President of Government Relations and Health Policy Josh Balloch urged patients to stay calm as the health care debate plays out on the nationwide stage. He pointed out that federal payments to subsidize care aren't set to run out for three years under the Republican plan.

"There is a lot of time to figure out the next step," he said. "I would encourage people to take a position and make their voices heard, but don't stress out."

The bill could still see many changes, and all sides are waiting for reports about financial impacts from the Congressional Budget Office, Balloch said.

"If the exact bill passes as written, Oregon would see a cut in funding," he said. "That would not be good for Oregon."

Patients not only would lose coverage from a repeal of the ACA, but the health care industry would take a hit.

"Health care is a major economic driver," Balloch said.

Repealing the ACA would cost 42,000 jobs in health care and other industries in Oregon, according to The Economic Policy Institute.

In the Rogue Valley, there are 14,200 jobs in the health care and social assistance industries, which are tabulated together because of their intertwining nature. Non-farm jobs total 84,820, according to the Oregon Employment Department.

Average pay for health care and social assistance jobs is approximately $53,500 annually, compared to average pay of $41,500 for all sectors, Oregon Employment Department data show.

A range of organizations concerned about health care, from the American Medical Association to the American Association of Retired Persons, have issued statements critical of proposed changes.

The Rogue Valley would be disproportionately impacted by health care cuts, said Scott Kelly, chief executive officer for Asante Rogue Regional Medical Center and executive vice president for the Asante system as a whole.

Asante's network includes hospitals in Medford, Ashland and Grants Pass.

Locally owned and operated, Asante is the largest employer in the region, with 5,400 employees, Kelly said.

He said Asante is seeing more patients with coverage because of the Affordable Care Act, and the number of uninsured residents has dropped. But cuts to reimbursement rates for Medicare, which serves senior citizens, help fund the Medicaid expansion for low-income residents.

Hospitals and other health care providers will be doubly hurt if Medicaid patients lose coverage and federal legislators don't restore the diverted funding to Medicare, Kelly said.

"We could end up with a significant challenge to our stability as health care providers in the state," he said.

Nationwide, 10.1 percent of people are 65 or over. That number increases to 16.8 percent in Oregon, and jumps to 21.3 percent in Jackson County and 26.1 percent in Josephine County, he said.

"We have a very large Medicare population to care for. Medicare and Medicaid are critically important," Kelly said. "They are more important here than in the rest of Oregon and in the rest of the country. The new legislation will likely reduce the levels of insured people."

Before changes are made to the Affordable Care Act and the American health care system, Kelly said potential impacts need to be thoroughly considered.

"It's my hope we understand what this is really going to mean in terms of access and affordability of care for people," he said.

— Reach staff reporter Vickie Aldous at 541-659-5740 or valdous@mailtribune.com. Follow her at www.twitter.com/VickieAldous.