Today, Colburn works on her brother’s farm and is covered by Medicaid. As a manual laborer, Colburn has developed nerve damage, which flares up in her hands and wrists with overuse. “I cut back my hours to deal with it. I can’t afford to not be able to use my hands,” she says. “That’s how I make all of my money.”

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As a child who grew up in a farming community, Colburn says she observed that pain is just a part of being a farmer. “It’s taken for granted that your body hurts every day, that your back always hurts.” That’s true for workers employed in some of the most dangerous jobs: Many manual laborers with high rates of injury and repetitive stress injuries are also more likely to be uninsured. In fact, a 2015 study found that 65 percent of commercial farmers identified health insurance costs as the most serious threat to their farms.

Alana Knudson, co-director of the Walsh Center for Rural Health at NORC at the University of Chicago, prefers to discuss rural health care in terms of strengths, but she does recognize the real barriers demonstrated by statistics. “Overall, we know that people who live in rural communities are likely to have lower incomes than their urban counterparts,” she says. Rural residents are also more likely to have multiple chronic conditions and lower educational attainment, and they’re more likely to face barriers in accessing transportation to medical care.

But there are also less tangible barriers. Colburn says that many people she knows don’t feel comfortable navigating the complicated web of professional medical interventions when experiencing health issues. And the Medicaid system can often lack efficiency. Colburn says her state’s website often doesn’t work, and she still hasn’t figured out how to find a primary care doctor who takes her insurance. Once, a computer glitch resulted in her being removed from her insurance plan, and she was charged hundreds of dollars in out-of-pocket expenses. Even though it was an error on Medicaid’s part, Colburn was still responsible for the bill. “Generally when we’re talking about rural health care issues, we’re talking about access, as if once you get access that actually means something. But when you get access, it still can be a nightmare,” she says.

Faced with whether to seek medical attention or “make do,” Colburn says many people simply don’t go. She notes that farmers especially have a hard time leaving their farm obligations to take care of themselves. They also spend significant time outdoors, and it’s difficult to imagine a hospital stay. Colburn says, “I have treated myself or not gone a million times.” One spring, she stepped on a potato fork and punctured her foot. Instead of going to the doctor, she spoke with a community herbalist, used an herbal tincture, and soaked her foot in salt water.

“I know for a fact that I need a root canal,” Colburn says, “It used to hurt and now it doesn’t hurt, so I just deal with it.” She pauses. “I know a lot of people who just get their teeth pulled. And the dental piece is important because what your teeth look like has [a] direct impact on what opportunities you have.”

This reality is echoed by rural journalist Sarah Smarsh. “In the past year, the Affordable Care Act, or ‘ObamaCare’, has changed many lives for the better—mine included,” she wrote in an essay for Aeon. “But its omission of dental coverage, a result of political compromise, is a dangerous, absurd compartmentalization of health care, as though teeth are apart from and less important than the rest of the body.”

*          *          *

The fabric of rural America is shifting, in large part due to changes in agriculture. Knudson grew up in North Dakota and says she’s seen that change firsthand. “Our neighbors are farming our land and they seed over 10,000 acres. A lot of the small farms are not there anymore.”

Many children of farmers choose not to take over the farm. Land is then sold or leased to larger farms. Small businesses that once depended on a critical mass of farm families as customers also go out of business. The effects of this rural migration are particularly severe on rural elderly with complex medical needs—and no younger generation remaining in the area to care for them.

Last year, a photographer and I drove across Kansas and Iowa to report on the hidden crisis of farmer suicide. We visited Onaga, Kansas, a small town with a newly renovated hospital. Just blocks from the hospital’s beautiful lobby and squeaky-clean floors were empty streets and boarded up storefronts. One doctor said the hospital had a hard time attracting medical professionals to practice there. The therapist had left months ago, she said, and they were struggling to fill the position.

An online search for “benefits for rural medical professionals” turns up a slew of sites about attracting medical talent to rural communities. Rural medical establishments are advised to advertise the lower cost of living and ability to buy acreage, less traffic, a quieter life, student loan forgiveness in certain underserved areas, “the potential to become the ‘town hero,’” more time spent with patients, and increased proficiency due to physicians seeing “a broader scope of illness.”

Still, rural communities are facing the closure of hospitals and clinics. In 2016, The National Rural Health Association (NRHA) announced that 673 rural hospitals were at risk to close. Of those, 210 were at “extreme risk” of closure. The NRHA warns that “Medical deserts are forming across the nation, significantly adding to the health care workforce shortage in rural communities. Seventy-seven percent of rural U.S. counties are already considered Primary Care Health Professional Shortage Areas.”

Knudson says the health care industry is undergoing a significant transformation in terms of how medical care is being reimbursed. “Our reimbursement system is moving from a volume to value,” she says. ”Historically hospitals have been reimbursed by the number of hospitalizations they provided—you have 10 hospitalizations and you get reimbursed for 10 stays. Our country has really shifted as much as possible to outpatient to make health care more affordable.”

That means a decrease in admissions, more outpatient procedures, and less reimbursable care for hospitals. Additionally, Knudson says many of the rural hospitals closing are in states that have not expanded Medicaid, which has led to a higher number of uninsured patients. “When people are uninsured, it’s difficult to collect payment for that hospitalization.”

Hospital closures can be devastating to rural communities, creating gaps in access to the detriment of residents. “Many of these hospital closures are happening in areas with the highest concentration of heart disease and diabetes, and in some of the poorest communities in the country,” says Maggie Elehwany of the NRHA. “When that hospital closes, it’s like putting a nail in the coffin of that community. You can’t attract businesses or families with kids or keep retirees. So we’re fighting not only for rural hospitals, but also for the economies of these rural communities as well.”

In June 2017, Missouri Congressman Sam Graves introduced the Save Rural Hospitals Act (H.R. 2957). The bill doesn’t increase reimbursements, but it does offer stability for “the closure crisis” by eliminating cuts and Medicare Sequestration for rural hospitals. It also establishes a new Medicare payment designation, called the Community Outpatient Hospital, that would guarantee rural access to emergency care and give hospitals the choice to offer outpatient care. The bill was co-sponsored by 21 representatives (14 Republicans and 7 Democrats), but it is still waiting for a vote.

*          *          *

Rural residents can’t afford to wait, so they are using the assets they have. Rural communities are known for being innovative, self-sufficient, and used to organizing quickly in an emergency. Families may have been rooted in one area for generations, which manifests in a deep knowing of their neighbors, as well as each other’s talents and stressors. And rural communities are often filled with people who want to help one another.

One story Alana Knudson tells me goes like this: One winter, in a northern rural community, an elderly man was treated for chronic urinary tract infections. He was treated and advised by medical staff to flush his kidneys as much as possible by drinking water. But he soon returned with another infection. When a community health worker visited his home, she discovered the man lived in the back of a shed, did not have an indoor toilet, and had to haul his own potable water.

At last, the urinary tract infections made sense. Knudson says, “It was not easy for this elderly man to traverse the snow and the cold in the dark to access the outdoor restroom, so he limited his fluid intake which contributed to reoccurring UTIs.”

To serve the health care needs of the nearly 60 million Americans who live in rural communities, Knudson says “it takes an entire team.” Ideally, Knudson says community health workers are part of that team. As public health workers who are also trusted members of the community, community health workers are particularly equipped to provide valuable connections between health or social services and the community. Primary care providers, pharmacists, social workers, health departments, and even agriculture extensions are critical members of the rural health care team. Knudson says, “A lot of different entities come together and complement each other. We can’t afford the luxury of duplication, so we really work together.”

“People come together to support others,” she says. “In my home community in North Dakota, we had a neighbor who had a heart attack during harvest, and all of us got together and finished the harvest for him. If you needed the help, you could count on your neighbors doing that.”

This frame is important, Knudson says, as much of the media attention about rural communities has been negative. As a result, she says, “There is such dystopia about rural America. We’re hearing from some rural communities that potential businesses are saying ‘we’re not interested in investing in rural America.’”

So far the debate on Capitol Hill—unlike the conversations taking place in town halls—has been abstract and detached. But for the millions of Americans living with the uncertainty and inevitable consequences of these decisions, these numbers are deeply personal. Congress is arguing about their health, and the stress of it all is making them sick.

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Alaskan small-business owners Colleen Mondor and her husband, Ward, are two of the 24 million Americans who stand to lose coverage if the new bill passes. They have not had a single night of uninterrupted sleep since 2005—that’s when their then-3-year-old son was diagnosed with a rare form of Type 1 diabetes that requires them to wake up to check his blood sugar.

Colleen and Ward are both cancer survivors, and before the Affordable Care Act they got their insurance through a $1,000 per month high-risk pool that required them to pay $10,000 out-of-pocket before their coverage kicked in. They have the coverage they need now, but the years of fighting to get and stay insured has taken a physical toll on their health.

“Luckily, nothing bad like the return of cancer, but we both experience intense, hallucinatory migraines and severe exhaustion,” Colleen says. “I think about stress all the time… I never thought as much about insurance before but now feel dread and a sick feeling in my stomach every year when we receive the letter to re-enroll. Until you face the threat of losing or not being able to get quality insurance, you just don’t know.”

The Republicans’ new health care bill will usher in insurance plans that will cost more but cover less, forcing millions of Americans to choose between the care they can afford and the care they need. When a family lacks the security of quality health insurance, it too often leads to greater financial burdens, instability, and increased stress levels that produce poorer health outcomes. That will add to the strain of an already stressed-out nation, jeopardizing the health and well-being of folks who can least afford to be sick.

Though its toll is often poorly recognized and underestimated, the cumulative wear and tear of stress leads to an increased risk of illnesses like high blood pressure, depression, and heart disease. It even accelerates aging and may cause premature death. That’s compounded by any unhealthy, inadequate coping habits, like smoking or substance abuse, which make the harmful effects even worse.

As the gap between the rich and the poor continues to widen, individuals and families struggling to maintain financial security are being exposed to unprecedented stress levels, and the impact is grave. People of color and individuals struggling with poverty, who bear the brunt of the growing inequality, are also absorbing the impact of the deadly stress that comes with it.

President Trump and the Republican-controlled Congress are pushing a health care plan that casts millions of already chronically-stressed Americans—like Colleen Mondor and her family—into an even more dire state of anxiety as they struggle to find new coverage (let alone good, affordable insurance). But right now, the House of Representatives has a choice: They can move forward with their destructive health care law, or they can reject it and develop a plan that doesn’t threaten the health care—and actual, physical health—of millions of people.

As for Colleen, she’s also hoping for something that should have been present all along.

“Empathy is the major missing component in this conversation,” she says. “I always say: you are fifteen minutes away from being me.”

Her symptoms first appeared a little after she turned one. She still wasn’t walking or crawling, but otherwise she was healthy and was hitting her milestones—she could say about a dozen words, feed herself, and play with her toys. But when she was around 14 months old, we noticed that Caroline was making repetitive movements with her hands that didn’t seem voluntary. Within a couple of weeks, she started losing her words and choking on her food. Eventually, she started losing her ability to hold things with her hands. We finally got her diagnosis when she was 17 months old.

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Now Caroline takes about ten different medications, multiple times a day. She takes 4 different types of medication for her seizures, which she has about 90 times a year. Without them, she would probably seize all throughout the day, every day. She undergoes a couple of hours total of lung treatment every day to avoid pneumonia,  and takes other medications to relax her stiff body, make sure she doesn’t vomit all the time,  and help her sleep. Her involuntary movements keep her up at night, and if she didn’t take medication she would only get a couple of hours of sleep every night.

Without Medicaid, I don’t know if we’d be able to afford this treatment. For Caroline, this is a matter of life and death.

Medicaid also offers several hours of skilled nursing care, which allows me and my husband to hold jobs. Without that coverage, one of us would have to quit our jobs—then we would not be able to afford all of the medical care that Caroline needs. That alone would put her life at risk.

I never imagined that I would have a child who would be dependent on us for every aspect of daily living for the rest of her life—from changing her diapers, to repositioning her to make sure she is comfortable throughout the day. And I never imagined that we would depend so much on a program like Medicaid.

But I also never imagined that I could love someone this much.

I want Caroline to live. I want her to feel safe, I want her to feel loved, and I want her to live in our home so that I can take care of her for as long as she is alive. Medicaid is the only way for us to be able to do that.

I would like to invite President Trump to meet Caroline and spend time with her, or with other kids like her. I think he would see first-hand how Medicaid helps us function as a family.

For more than a year I was unable to speak, sit up, or eat solid food. In June 2015, first responders wheeled me into the emergency room, too weak to eat, drink, or elevate my head. I had been, essentially, waiting to die of dehydration. Besides administering some much-needed fluids, doctors offered little help.

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I have among the most severe cases of chronic fatigue syndrome (sometimes known as myalgic encephalomyelitis, or ME). It’s a devastating multi-system disease that’s been given a patronizing name. The cause is still unknown, which makes getting a proper diagnosis—often necessary for insurance and disability coverage—near impossible.

When I was released from the hospital in 2015, my family learned that California’s state-administered Medicaid health care program, Medi-Cal, would not cover the ambulance ride to transport me home because none of my conditions were considered “legitimate.” I took the ambulance anyway, and paid around $1,500 for the ride out-of-pocket.

Several months later, I became so dehydrated that my family decided to pay more than $150 a day for a nurse to come to our house to administer intravenous saline to keep me alive. Large doses of intravenous saline were, and still are, the only way to keep my body functioning.

My medical care has become a privilege that costs me more than $1,200 a month. In the last year, I spent roughly $73,000 on my health care—more than double my annual income when I was healthy and working full-time.

Historically, the National Institutes of Health (NIH), has allotted only a paltry amount of attention and funding—$6 million—to ME research. Some headway has been made in recent years, at least in part because advocacy through the #MillionsMissing campaign has brought the lack of funding to legislators’ attention. In November 2016, the NIH tentatively announced plans to increase research funding for ME to roughly $15 million for fiscal year 2017. But now, with Republicans controlling both Congress and the White House, there has been a change in what was promised. In January the NIH said it will actually decrease funding, allotting $1 million less than in 2016.

The amount is minuscule compared to the funds that the government has at its disposal. The ME community has needed a substantial increase in government funding for decades. More funding would mean more research; more research would mean more biomarkers; and more biomarkers would mean the potential for a diagnostic test. These scientific breakthroughs would mean medical professionals would be able to better understand the disease—and therein lies the solution. This path has potential for the medical establishment and government to compensate for decades of belittling patients who suffer from a devastating disease, finally bringing widespread legitimacy to ME—and relief to millions of patients. That would be real progress.

But it may never happen at all.

Before Donald Trump shocked the world by winning the election, I was hopeful that the Affordable Care Act (ACA) would, in time, be expanded so that more of my medical needs would be covered by insurance. But now, barring a radical turn of events, that seems—at best—highly unlikely.

If the Trump Administration repeals the ACA, even simple treatments—like saline infusions and in-home nurse and doctor visits—will cost egregious amounts of money. My savings account has been zeroed-out, and I receive less than $900 in monthly disability checks. For the past year, my medical expenses alone have been more than $6,000 a month.

The plans that have been floated to replace the ACA do little for people with disabilities or low incomes. A replacement would likely offer a flat credit based on age, and it wouldn’t cover the care I need.  It would also dramatically weaken Medicaid, decimating services for people with disabilities and serious illnesses.

It would be unfair to say that the ACA has no room for improvement. But for me—and I imagine for most poor, chronically ill people—it is something to build on, not something to dismantle.

Because what happens next, for us, could be a matter of life or death.

Ten years ago, before the Affordable Care Act was passed, I became a 26-year-old widow with a 2-year-old child.

I want to tell you about how health insurance changes lives—how it can save them, and what is lost when it fails.

My late husband Bob and I met when I was only 13. Bob was a wise old man of 15. Everyone liked him—he was the kind of person who made other people feel good about the world and about themselves. I liked him right away, and we started dating after he asked me to go to a dance. We were the rare high school sweethearts who maintained a relationship through college, even though Bob was two years ahead of me in school.

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Bob was a musician and an educator. He earned a Master’s degree in music, and performed in St. Louis and towns all over the Midwest. His income from those gigs was a very significant part of our household budget. He taught at jazz camps for kids, and as an adjunct faculty at various local colleges. Bob loved teaching. A lot of people teach because it’s a reliable source of income to support their passion for performance, but Bob taught because he loved being with students. He was incredibly methodical and organized in his approach to teaching. Many of his friends and former students are still teaching music today using his methods and materials at various institutions in and around my hometown of St. Louis.

Bob was also a gifted composer, because he had worked hard to learn theory and technique until they obeyed the commands of his heart. He spoke the language of music far more eloquently than most of us ever speak with words. I didn’t recognize Bob’s gift when he was living as well as I do now. After he released a CD in 2004, the American Society of Composers, Authors and Publishers (ASCAP) selected him to receive a Young Jazz Composer’s Award for one of his songs, “Nola’s Waltz.” As my own musical understanding grows, I hear more and more of what he had to say and how beautifully he told his stories.

He was certainly living the dream in those years—from 1997, when his musical career started, until 2007, when it abruptly came to an end.

What happened?

When he was 25, Bob started having stomach aches. We were married, expecting a child, and working ten jobs between the two of us. I had three jobs and was a full-time student, and Bob taught at six different places in addition to his performance gigs. None of these jobs had paid sick days, so when Bob had stomach pains, he just went to work anyway.

Health insurance was always a problem for us. We purchased it through our college when we were students, but when Bob graduated and we tried to find our own insurance most companies rejected us because Bob was overweight and had a pre-existing condition: he had taken medication for acne when he was in high school. We were able to purchase a catastrophic insurance policy, but it had a deductible of $5,000 and cost us a little less than that each year in premiums.

About 20 percent of our income at that time was going toward medical expenses. We were racking up debt, and paying quite a bit of interest on it. In hindsight, we probably restricted our access to care. Just paying the premiums was enough of a financial burden—we did not want to add to it with copays.

Bob’s stomach aches got gradually worse over time, until he finally went to the ER. We both thought he was having a heart attack, because he was so sweaty and clammy and in so much pain. He was diagnosed with gallbladder problems, and we were relieved that it wasn’t something worse.

In a follow-up visit to the doctor, Bob was told that he didn’t have to do anything until the pain was bad enough to warrant having his gallbladder removed. So Bob muscled his way through the attacks, even when they were so bad that he was literally crawling in pain. It was very frustrating for me as his wife. I was angry with him because he refused to go to the doctor and get his surgery to get that gallbladder out.

Starting in the 2006-2007 school year, Bob was hired as a full-time faculty member of Southwestern Illinois College (SWIC). We had employer-based health coverage for the first time, and he was not about to risk losing that right when we got it by calling in sick for a few weeks. He was determined to stick it out until the end of that school year to do the right thing for his job—and his wife and son.

On March 22, 2007, Bob called me at home and told me that he was having an attack at work and that I needed to come get him and take him to the hospital. I drove him to the ER with our 2-year-old in tow, and the three of us spent the entire night in a hallway in the hospital basement. Bob was delirious from pain and sedation. He had acute pancreatitis, which was caused by a gallstone that had escaped his gallbladder and lodged itself in his pancreas.

Bob spent three weeks in the ICU at that hospital, was airlifted to a bigger hospital, and spent another three weeks in the ICU there.  His last words to me were all confusion about why he was in the hospital and why no one would let him go home. He just wanted to see his son.

In the middle of the night on May 3, a nurse called to tell me that Bob had taken a turn for the worse. I called his friends and family, and we sat vigil for him in the waiting room. There were probably 30 of us there when a nurse told me he was the sickest person in the hospital.

His death came at the end of a desperate, gory fight to save him. If you’ve never watched someone die of sepsis, I hope you stay that way.

Bob’s funeral was attended by at least 600 people. It was beautiful. People came together to express their grief by supporting his family. I was amazed at how caring people can be. I also barely remember it, because I slept so little in those days. Bob’s death left me adrift as a 26-year-old widow and single mother with few job prospects. I was still in the middle of my own education when he died.

Things worked out far better for me than they do for most people in my position, thanks to Bob’s life insurance, health insurance, and Social Security. Since Bob was covered by his employer’s health insurance, the medical bills that packed my mailbox for months after his death—I lost track of the total after it topped a quarter of a million dollars—were covered. They didn’t force me into bankruptcy, so I was able to rebuild our life. I spent countless nights grieving alone and struggling to work around the hole in my heart, and I spent my days going to school and raising our son, Bobby. I earned a Master’s Degree in Art Therapy Counseling, and provided more than 1,400 hours of services to others as part of earning that degree. I remarried in 2011.

It all could have gone very differently if the laws in our country had been on a slightly different timeline. If the ACA had passed in 2004 instead of 2009, Bob and I would have had coverage we weren’t afraid to use. Bob would have been covered by his parents’ insurance until only two months before his employer-based coverage began. He could’ve had his gallbladder taken out months before it killed him.

If the ACA is repealed—if we no longer prevent insurance companies from excluding people based on pre-existing conditions like teenage acne, or no longer require insurance companies to cover young adults when they may not yet work the kinds of jobs that provide health insurance—then there will be many more stories like Bob’s. There will be many more incandescent American lives that flicker out.

If we lose these provisions, my own experiences will inform the health care I’m willing to procure for my children. Perhaps I’ll decide that it’s better to leave my children’s allergies and minor illnesses and acne untreated, knowing that a diagnosis as a child could prevent them from being able to access more important health care as an adult.

Is that really the best we have to offer our children?

I know the ACA isn’t perfect—our employer-based coverage premiums and copays have gone up. Insurance policies change too often. But at least we have coverage, and under the current law we aren’t afraid we will lose it if we use it.

That is worth protecting. Find a way to do it.

Severe economic pain was widespread—more than 10 million people were unemployed, up from 7 million before the crisis.  No one was hit harder than communities of color, where residents who should have qualified for prime loans had been targeted and steered toward higher-priced exotic subprimes, then lost their homes to foreclosure. As reporter Jamelle Bouie put it, the loss of wealth represented “a generation’s worth of hard work and progress wiped out.”

This was the economy our nation’s first African-American president inherited.

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Barack Obama’s work to respond to hardship and deprivation began before he even took the oath of office, when he ordered his transition team to develop what would become the American Recovery and Reinvestment Act (Recovery Act).  He signed the bill into law in February 2009.

The Recovery Act was one of the most powerful pieces of antipoverty legislation passed in decades. It extended tax credits to more people who worked in low-paying jobs—a reform that eventually became permanent, and helped lift nearly 10 million people out of poverty last year alone. It prevented more than a million home foreclosures, saved or created up to 3.6 million jobs, and helped families and communities survive the economic havoc that had been unleashed by a reckless Wall Street.

Princeton economist Alan Blinder and Moody’s Chief Economist Mark Zandi estimate that without the Recovery Act we might have faced a depression, with 17 million lost jobs (instead of about 8 million), and a peak unemployment rate high of nearly 16 percent (instead of 10 percent).  The Recovery Act’s expansion of the safety net also kept more than 6 million Americans out of poverty.

Immediately following passage of the Recovery Act, the President began work on healthcare reform, eventually signing the Affordable Care Act (Obamacare) into law in March 2010. The legislation established historic economic protections. Gone is the ability of insurance companies to reject people for coverage on the basis of pre-existing conditions.  Gone was the chance that Americans would be too poor to afford insurance, but not poor enough to qualify for Medicaid (until the Supreme Court got involved).  And gone is the chance that young adults would be cut off from their parents’ plans.

More than 22 million Americans have gotten health insurance through Obamacare, and the share of Americans without health insurance has dropped to a record low.  The law also protects millions of low- and moderate-income families who would otherwise be a single health crisis away from poverty.  Vice President Joe Biden described the significance of the legislation perfectly when he said, “This is a big f—ing deal.”

Once the Affordable Care Act was in place, Obama began working with Congress to tackle some of the root causes of the Great Recession—including the actions of “too big to fail” financial institutions. The Dodd-Frank financial reform law established the Consumer Financial Protection Bureau (CFPB) to protect consumers from unfair, deceptive, or abusive practices, and to take action against companies that break the law.

Throughout his term, President Obama worked tirelessly to make sure Americans have a fair chance at success. He launched the Promise Neighborhood and Promise Zones initiatives to improve economic opportunity in high-poverty communities—whether urban, rural, or tribal.  He signed the Lilly Ledbetter Fair Pay Act, which makes it easier for women to file an equal pay lawsuit. He issued Executive Orders to raise wages for federal government contractors, updated a meek Overtime Rule in order to raise working-class wages, took executive action to help ensure that people aren’t held back by a criminal record, and created the Deferred Action for Childhood Arrivals (DACA) program to protect undocumented children and young adults from deportation.

The president also drew attention to issues that have been neglected for far too long, ranging from criminal justice reform, longstanding federal policy failures on American Indian and Alaskan Native issues, and science-based nutrition standards for school meals.  And he accomplished all of this while most Republicans in Congress refused to cooperate on virtually any of his proposals—a tactic stated explicitly by Senator Mitch McConnell, among others.

To be sure, the legacy is not all positive and the work is not complete. The economic recovery following the Great Recession was extraordinarily slow and painful for far too many of us—and many people haven’t recovered at all. He could have prevented more foreclosures by forcing banks to modify mortgages.  DACA and the Overtime rule were blocked by the courts, food and nutrition assistance programs were cut nearly as quickly as they were expanded, and revenues were never increased sufficiently to meet the nation’s long-term antipoverty and infrastructure needs.

That said, President Obama’s legacy is one that demonstrates a tireless commitment to making the American Dream accessible to all Americans.

As we now approach the swearing-in of President-elect Donald Trump, just about everything we have alluded to here, and much more, is in jeopardy.

That’s why in the coming weeks, TalkPoverty’s series examining Obama’s legacy will focus not only on poverty and inequality, but on what’s at risk under a Trump administration. It will address how we can protect—and eventually expand—the gains we have made over the past eight years.

No one will be more vulnerable to the changes proposed by Trump and his Republican allies than people who are already struggling. We need to be ready to fight as if lives are at stake—because they are. 

Editor’s note: TalkPoverty presents this series in collaboration with the Georgetown Center on Poverty and Inequality.

But all that changed this February when I was sitting on the train on my way to my graduate class and felt my heart race. I wasn’t nervous or stressed, but could feel my pulse thundering throughout my body—the type of feeling you get when your professor is cold-calling students with questions and you haven’t done the reading.

Chastened, I resolved to start running again and cut back on my caffeine. But my palpitations didn’t go away. After two months of diet and exercise (and persistent chiding from my mother), I reluctantly went to the doctor. I didn’t expect much to come out of it. Why would I need to see a doctor? I was young and healthy and heart problems only happened to older people—I was a young invincible.

My first real sense of concern arose when the nurse practitioner put her stethoscope to my chest and her eyes widened. She proceeded to tell me that I had a very clear heart murmur, a whooshing sound indicating turbulent blood around my heart. An echocardiogram later revealed a mitral valve prolapse, and a subsequent test showed significant regurgitation.

Put into plain English, one of the valves of my heart doesn’t close properly, allowing blood that should be pumped out of my heart to spill back in. In cases like this, the heart compensates and pumps harder to keep the blood out. My doctor recommended mitral valve repair surgery, an open-heart surgery that will require me to stay in the hospital for at least five days after the operation, followed by four to six weeks’ recuperation.

And so, in a period of three months, I went from being a healthy young adult to one in need of heart surgery. I was shocked, but in some ways I was lucky. I was insured, thanks to the Affordable Care Act.

The ACA helped me when I transferred from a full-time position to a part-time one and lost my employer-provided health insurance. After conversations with multiple people about the risks of forgoing health insurance, I decided to purchase coverage through the New York marketplace.

I am incredibly fortunate that I chose—and was able to afford—the route of subsidized insurance premiums. While the cost for mitral valve repair surgery before insurance is around $30,000, the entire ordeal can cost upwards of $200,000. With that high of a price tag, the surgery would have financially crippled me. But due to my insurance, I will only be responsible for copays and deductibles.

I cannot imagine the stress of knowing I could not afford a surgery that could save my life. But that’s a reality for too many Americans—particularly millennials of color—even though the ACA has resulted in the largest gains in coverage in decades. These gaps are in part due to the fact that 20 states have refused to expand Medicaid, which has meant that 3.1 million otherwise eligible adults fall into what is known as the “coverage gap”—they earn too much for Medicaid but too little to access the subsidies they need to afford insurance. Of that group, nearly half are adults aged 19 to 34.

The fact that vulnerable people have been left without insurance doesn’t seem to bother some on the right, including governor-elect Matt Bevin of Kentucky. Although the state has already expanded Medicaid, Bevin has promised to dismantle the state-run Kynect exchange, leaving over 300,000 people that were previously covered through the expansion without affordable health insurance. This disastrous move would undo the immense good that the policy has achieved, including the second largest drop in uninsured rates in the nation.

Furthermore, the Senate recently passed a bill that can only be described as highly destructive. The proposed legislation would nearly double the number of uninsured Americans by dismantling Medicaid expansion for the 30 states, plus the District of Columbia, that have already implemented it. Simultaneously, it would eliminate subsidies that help low-income people purchase coverage.

This proposal represents a callous disregard for the lives of low-income Americans. We should be removing barriers to insurance, not impeding paths to coverage. I hope that our elected officials consider the human costs of their decisions and remember citizens like myself whose lives might depend on accessing that coverage.

Now, I watch and wait for the Supreme Court’s Decision in King v. Burwell and the looming budget fight—each of which will decide the fate of the Affordable Care Act, a law I could have used in 2010.

Back then I was in the best shape of my life. Years of walking to work had helped. At 26, I learned to ride a bicycle and for one month, I flew. The hour that it took to get to and from work became fifteen minutes. I could buy cold food in the summer again. Bowling Green, Kentucky became small enough that I no longer had to factor in travel time.

And then I played basketball.

My best friend at the time, Emily, texted me asking me to meet her at her apartment so we could walk over to the nearby basketball court—which was actually just a basket at the edge of a church parking lot—and shoot hoops for a couple hours. Emily played basketball in high school and I lack basic hand-eye coordination skills, so when I landed awkwardly after coming down from a layup, grabbing the post for support, she didn’t think anything about it. But then, I didn’t let go. I held my left foot off the ground.

She asked me if I was alright and I told her I hoped so. She asked me what it felt like and the first thing that came to mind was that scene in Indiana Jones and the Temple of Doom when Indy drops the guard into a rock crusher. Emily cringed and asked me which hospital we should go to.

I laughed.

She asked me what I wanted to do since I wouldn’t go to the hospital. I didn’t know. I asked her to bring me my phone. She came back with it and asked me if I’d be okay if she left for a minute. She was going to get me an ice bag and a slushie. Blue Raspberry.

Slushies make everything better.

I laid down in the parking lot and watched its parking lights go out and called the owner of the restaurant I worked at. When he asked me about the hospital, I could only manage a chuckle. He asked me what he could do for me and I asked him if he had the crutches he brought back from his last failed ski trip and if I could borrow them for a while. “Absolutely.”

Next, I called a couple of the marijuana enthusiasts from work and asked them to meet me at my apartment. An hour later we met up at the front door and Emily helped me climb up the flight of stairs while the others kept asking why I couldn’t go to the hospital. “Obamacare passed,” they said. “It hasn’t kicked in yet,” I answered.

I fell onto my bed and waited while the saintly stoners sparked a joint. While it worked wonders otherwise, the weed wasn’t strong enough for my ankle. Even though I didn’t feel any better, I was content not to care.

The next day my roommate, Travis, drove me to work for comfort food—a Reuben. While I sat in the dining room with my engorged ankle propped on a chair, one of my new hires came over to me and asked what I meant to do about the ankle. “First, I’m going to eat this Reuben. Then, I’m going to go to Lowe’s and get some scrap wood and nail together a brace… thing.” She smirked and told me her fiancé was an MMA fighter (the pale guy), that he broke his foot the year before and held on to the walking boot. “I mean, you shouldn’t walk on it now, but it’ll hold it in place until you can.”

I was on the crutches for six weeks.

I gave up on trying to self-medicate. Not only did the weed fail to do the trick, but also Kentucky’s burgeoning crackdown on prescription drug abuse meant that I couldn’t score so much as a pity Vicodin. I stayed in the walking boot for six months and even managed to shower four times a week without falling.

Then, one day in November, I woke up, strapped my leg into the boot and started itching. My leg wouldn’t go for the walking boot anymore. I grabbed the cane I had bought to mark the occasion and headed down the stairs and out the door. What had been a ten minute walk down to the city square took twenty. My left leg was half the size of my right. When I got on my bike I had to pedal twice as hard with my right leg as I could my left.

I was lucky when I broke my ankle. I knew the right people and (the Commonwealth notwithstanding) could procure the right supplies.

But there is a reason this story stays with me: I live in the USA, the richest, most powerful country in the world. Why did we and do we leave our health and well-being up to luck? Shouldn’t the “Shining City on a Hill,” the birthplace of modern democracy, the land of the free be shining and modern and free enough to manage the health of its citizens with something other than luck?

That’s something to celebrate – but the celebration could be short-lived for many people. Instead of figuring out how to get more people health coverage in 2015, many newly-elected and re-elected state legislators and governors are actually plotting how to take health care away from people who just received it for the first time.

It’s a real threat to people who’ve just gained coverage through Medicaid expansion – especially in states where incoming lawmakers are openly hostile to anything related to the Affordable Care Act. Those at greatest risk of losing coverage are women and people of color.

In Arkansas, where 211,000 people recently gained coverage, the state legislature must reapprove the Medicaid expansion plan by a three-quarters majority again in 2015. The incoming Republican governor is unenthusiastic about the plan – and expansion opponents won seats in the legislature. That doesn’t bode well.

In Ohio, where more than 400,000 people have coverage under Medicaid, the state legislature is also required to reauthorize the program in 2015. And in New Hampshire, where more than 20,000 people enrolled in just three months, the new Republican majority in the NH House of Representatives will also take a fresh vote on the program as well.

The continuing failure of more than 20 states to adopt any expansion plans at all, and the prospect of newly elected legislators revoking expanded coverage for hundreds of thousands of residents, represents a serious health threat to women.

A recent 50-state report card on women’s health by the Alliance for a Just Society clearly shows that most of the states that rejected Medicaid expansion have poor or failing records on women’s health. When it comes to ensuring that women have access to health care, the majority of legislators in these states have turned their backs on women.

The 2014 Women’s Health Report Card ranks and grades every state in the country on 30 distinct measures of women’s health. The results: 17 of the 21 states that rejected Medicaid expansion received final grades of C, D or F – and 13 of those states received a D or F.

Politicians in these states are failing women, but they are especially failing women of color who are more likely to be working low paying jobs, not covered by health insurance, and are least likely to have access to medical care.

The number of black women without health insurance is at least 20 percent higher than for women overall in 17 states. The uninsured rate for Latina women is at least 50 percent higher in 44 states. Black, Latina, and Native American women without access to health care have dramatically higher rates of hypertension, diabetes and infant mortality than other women.

While it’s encouraging news that Wyoming, Montana, and even Idaho seem to be moving toward Medicaid expansion, it will also leave our nation with a disturbing illustration of how alive and well racial segregation is in America. Take a look at the map of states that are refusing coverage to their most vulnerable residents: being denied access to health care is the latest Jim Crow.

Lawmakers in states that haven’t expanded Medicaid yet should move quickly to adopt expansion plans this year. If they don’t, they will bear the responsibility for their states falling even further behind on women’s health, and worsening racial disparities in our health care system.

As for lawmakers considering a vote to take health care away from thousands of their constituents, all I can ask is: Seriously? Do you really want to do that?

It’s one thing to stand in the way of people gaining access to quality, affordable health care. But it’s something else when people have just experienced quality, affordable health care for the first time, and then you snatch it away from them.

I can’t imagine that many will take kindly to it. And just in case anybody’s forgotten, there’s another election just a couple years away.

The short answer is that over a half million people – in a state of only 4.4 million – sign up for healthcare. About 75 percent of those who signed up didn’t previously have health insurance, so the uninsured population has dropped by 42 percent and the uninsured rate has gone from more than 20 percent to less than 12 percent.

Although the health-care exchanges that were created by the Affordable Care Act have gotten most of the news coverage so far, it’s the expansion of Medicaid that has had the biggest impact, with about 80 percent of the newly insured in Kentucky getting coverage through Medicaid.

In the Supreme Court’s June 2012 decision upholding the constitutionality of the Affordable Care Act, the court ruled that states could opt out of the Medicaid expansion without losing any of their current Medicaid funding. Many policy analysts didn’t think the ruling would have a major impact, since the federal government is paying for the entire expansion for the first three years and gradually reducing to 90 percent in 2020. As MIT healthcare economist and Affordable Care Act architect Jonathan Gruber put it, “When the Supreme Court decision came down, I said, ‘It’s not a big deal. What state would turn down free money from the federal government to cover their poorest citizens?’”

More than a few, as it turns out.

Only 27 states and the District of Columbia have opted into Medicaid expansion.  In Kentucky’s case, it found that expansion would actually save money, delivering a $15.6 billion boost to the economy while creating almost 17,000 jobs—all while insuring its most vulnerable citizens. As Governor Steve Beshear wrote in a New York Times op-ed defending the decision, “…to those more worried about political power than Kentucky’s families, I say, ‘Get over it.’ … and get out of the way so I can help my people. Here in Kentucky, we cannot afford to waste another day or another life.”  He called the reform “the single most important decision in our lifetime for improving the health of Kentuckians” and said the state would “come out ahead in terms of both health outcomes and finances. In fact, if we don’t expand Medicaid, we will lose money.”

In contrast, as Gruber notes, the states choosing not to expand Medicaid “are not just not interested in covering poor people, they are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.”

The non-expansion states already have, on average, poorer health outcomes and large uninsured populations, and now they will fall even further behind healthier states. The difference is already visible in survey data, according to Gallup.

If the 23 states that haven’t expanded Medicaid were to instead opt-in, nearly 7 million additional people would likely receive coverage. These states are also passing up on more than $400 billion in federal funding.

This slow expansion of Medicaid is not unprecedented. In 1966, when federal funds for Medicaid were first available, only 26 states had programs up and running by the end of the year. By 1970, however, 48 states offered Medicaid. It wasn’t until 1982 that the last hold-out, Arizona, finally opted-in.

One of the tricks for providing healthcare in states where Obamacare is politically unpopular is—well, not too tricky: call it something else. Although ‘Obamacare’ remains unpopular in Kentucky, ‘Kynect’—the name of the state’s health insurance exchange—is popular.

The faith community is also playing a major role in pushing for expansion, arguing that it is a moral issue, and noting Jesus’ role as a healer. Rev. Raphael Warnock, the Senior Pastor of Ebenezer Baptist Church in Atlanta, reminded policymakers that the millions of people caught in the Medicaid gap “are not numbers, these are our church members and family members. So for us, this is a matter of life and death.” Towards the end of August, the Moral Monday Movement marched on 12 state capitols urging governors and legislators to expand Medicaid.

In my own church in Kentucky, I have already seen the benefits of expansion.  One of our members who works for wages that are too low to afford health insurance, but were too high to qualify for Medicaid prior to expansion, finally has access to healthcare. For the first time she stopped worrying about what would happen to her if she were to get sick before she was old enough to qualify for Medicare.

The Robert Wood Johnson Foundation and the Urban Institute have provided a state-by-state breakdown of what opting-out of Medicaid expansion is costing in both human and financial terms. Find out what your state is missing out on, and then urge your decision-makers to follow Kentucky’s lead.

Editors Note: Listed states had not expanded eligibility as of July 2014. They include Indiana, Pennsylvania. and Utah, which have pending waiver proposals to expand eligibility. Totals may not add because of rounding. Note that Pennsylvania announced last month that it will expand Medicaid.