As the nation has debated the GOP proposals to repeal and replace the Affordable Care Act, NPR member station reporters have been talking to people around the country about how the proposed changes in the health law would affect them.

Here are five of those stories:

A young man with Parkinson’s Disease. Ford Inbody is already thinking about a time when he won’t be able to work. He is 33 and was diagnosed with early-onset Parkinson’s disease. While many of his Millennial friends are starting families, he and his wife have decided not to have children, and they’re carefully planning for the future where he will have to give up his job. Changes that make it harder to afford coverage for pre-existing conditions could affect him drastically. He’s hoping he would be able to buy insurance on the exchange once he’s no longer covered through work, and that eventually Medicaid would be there for him if and when the disease leaves him disabled. —- Reporting by Alex Smith, KCUR, Kansas City, Mo.

A farmer hopes stay insured until he’s old enough for Medicare. Darvin Bentlage says his health insurance plan used to be the same as all the other cattle farmers in Barton County, Mo.: Stay healthy until he turned 65, then get on Medicare. But when he turned 50, things did not go according to plan. He had some health problems, had to refinance his farm to pay those medical bills, and then went without insurance for a while. He says he signed up for insurance on the exchanges established under the Affordable Care Act as soon as he could. If he loses subsidies or gets charged more for his pre-existing conditions, “I just have to go back to plan A and hope I make it to 65,” he chuckles. — Reporting by Bram Sable-Smith, KBIA, Columbia, Mo.

A Man With Down’s Syndrome Gets By With A Little Help From Medicaid. Evan Nodvinhas a job at a fitness center, lives in an apartment and feels so passionately about keeping his independence, he went to Washington to lobby when he heard about potential cuts to Medicaid under GOP health care plans. “My life is very full,” he said. “I work, live and play in the community. My dream is to continue this healthy and useful life.” A few decades ago, states closed many institutions that took care of people with disabilities in hopes of that they would be integrated into the community. Many can, but with some support. Medicaid is often that support, with the majority of money going to help people with disabilities. — Reporting by Elly Yu, WABE, Atlanta.

A young woman breaking her addiction to opioids.Charlene Yurgaitis, 35, decided after a decade of using opioids, she was ready to tackle her addiction. And she is doing it full-on, with medication-assisted treatment combined with counseling. Medicaid is her insurance, for which she became eligible when Pennsylvania expanded the insurance program under the Affordable Care Act. “I would never be able to afford counseling,” she says. “I would never be able to afford psych meds. I would never be able to afford the Vivitrol shot.” She says she’d say to lawmakers who want to curtail federal spending on Medicaid, “Why are you trying to change something that’s working?” — Reporting by Ben Allen, WITF, Harrisburg, Pa.

A self-employed veteran in California. Air Force veteran Billy Ramos is a contractor in the heating and air conditioning business who is grateful to have Medicaid. He signed up when California expanded the health insurance program for low-income people under the ACA. About 1 in 10 veterans gets help from Medicaid; only about half of the 22 million veterans in the U.S. get care from the VA system. Ramos gets treatment for his hepatitis and feels relieved knowing he has emergency care if something goes awry on the job. —Reporting by Stephane O’Neill, freelance.

These stories are part of a reporting partnership with NPR, local member stations and Kaiser Health News.

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When high levels of lead were discovered in the public water system in Flint, Mich., in 2015, Medicaid stepped in to help thousands of children get tested for poisoning and receive care.

When disabled children need to get to doctor’s appointments — either across town or hundreds of miles away — Medicaid pays for their transportation.

When older middle-class Americans deplete their savings to pay for costly nursing home care, Medicaid offers coverage.

The United States has become a Medicaid nation.

Although it started as a plan to cover only the poor, Medicaid now touches tens of millions of Americans who live above the poverty line. The program serves as a backstop for America’s scattershot health care system, and as Republicans learned this year in their relentless battle to replace the Affordable Care Act, also known as Obamacare, efforts to drastically change that can spur a backlash.

The latest Republican proposal — spearheaded by Republican Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana — is being pummeled by doctors, insurers, hospitals and patient advocates because it would scrap the Affordable Care Act’s Medicaid expansion and reduce federal funding for Medicaid.

Senate leaders are trying to get to a vote before Sept. 30, when special budget rules that would allow them to need only 50 votes expire.

Today Medicaid is the nation’s largest health insurance program, covering 74 million people — more than 1 in 5 Americans. Twenty-five percent of Americans will be on Medicaid at some point in their lives — many are just a pink slip away from being eligible.

Medicaid funding protects families from having to sell a home or declare bankruptcy to pay for the care of a disabled child or elderly parent. It covers some aspects of disaster relief, public health emergencies and some programs in schools that lack other sources of funding.

Millions of women who don’t qualify for full Medicaid benefits each year obtain family planning services paid for by Medicaid. These women have incomes as high as triple the federal poverty rate — above $36,000 for an individual. And thousands of women who otherwise don’t qualify for the program get treated each year for breast and cervical cancers through Medicaid.

A proposal that would have deeply cut Medicaid passed in a House bill in May, but the ACA overhaul legislation fell short in the Senate in July. “Instead of cutting Medicaid, [lawmakers] increased public awareness of its value and made it even harder to cut in the future,” says Jonathan Oberlander, professor of health policy and management at the University of North Carolina, Chapel Hill and a supporter of the federal health law.

Medicaid is the workhorse of the health system, covering:

• 40 percent of all children,
• Half of all births in the U.S.,
• 60 percent of nursing home and other long-term care expenses, and
• More than one-quarter of all spending on mental health services and over a fifth of all spending on substance abuse treatment.

Unlike Medicare beneficiaries, who keep that insurance for life, most Medicaid enrollees churn in and out of the program every few years depending on their circumstances, government statistics show.

Such numbers underline the importance of Medicaid, but also provoke alarm among conservatives and some economists who say the U.S. cannot afford the costs over the long run.

Bill Hammond, director of health policy of the fiscally conservative Empire Center for Public Policy in Albany, N.Y., says Medicaid has been a big help for those whom it was designed to cover — children and the disabled. But it has grown so big that the cost hurts state efforts to pay for other necessary public services, such as education and roads. “I can’t think of any other anti-poverty program that reaches so many people,” he says. “It’s too expensive a benefit.”

“We need to transition people to get coverage in the private sector,” Hammond says, noting that millions on the program have incomes above the federal poverty level.

It may be the person down the block

Joana Weaver, 49, of Salisbury, Md., has cerebral palsy and has been on and off Medicaid since birth. For the past few years, it has paid for home nursing services for six hours a day to help her get dressed, bathed and fed. That has kept her out of a nursing home and enabled her to teach English part time at a local community college.

“For me, Medicaid has meant having my independence,” Weaver says.

Medicaid recipients include many grandmothers — one-quarter of Medicaid enrollees are elderly people or disabled adults.

And lots of kids qualify for Medicaid, too. About half of Medicaid enrollees are children, many with physical or mental disabilities

Many of the rest — about 24 million enrollees — are adults under 65 without disabilities who earn too little to afford health insurance otherwise. About 60 percent of nondisabled adult enrollees have a job. Many of those who don’t work are caregivers.

“It’s the mechanic down the street, the woman waiting tables where you go for breakfast and people working at the grocery store,” says Sara Rosenbaum, a health policy professor at George Washington University in Washington, D.C.

While all states rely on Medicaid, it’s used more in some places than others because of varying state eligibility rules and poverty rates. About 44 percent of all New Mexico residents are insured by Medicaid. In West Virginia and California, it’s nearly 1 in 3.

Jane and Fred Fergus, of Lawrence, Kan., say Medicaid has been a cornerstone in their lives since their son, Franklin, was born eight years ago with a severe genetic disability that left him unable to speak or walk. He is blind and deaf on one side of his body.

Although the family has insurance through Fred’s job as a high school history teacher, Franklin was eligible for Medicaid through an optional program that states use to help families let their children be cared for at home, rather than moving to a hospital or nursing home.

Medicaid pays all of the child’s medical bills, Jane Fergus says, including monthly transportation costs to Cincinnati Children’s Hospital, where for the past 18 months, he has been receiving an experimental chemotherapy drug to help shrink tumors that block his airway. The program also covers his wheelchair, walker and daily nursing care at home.

“We have such great health care for him because of Medicaid,” his mother says.

Jane Fergus was never politically active until this year, when she feared that the GOP plans to cut Medicaid funding would reduce services for her son.

“If there is a silver lining in all this debate, it’s that we have been given a voice, and people in power are being educated on the role of Medicaid,” she says.

Moving beyond its roots

Medicaid was born in a 1965 political deal to help bring more support for President Lyndon Johnson’s dream of Medicare, the national health insurance program for the elderly.

Over the past 40 years and particularly since the 1980s, Medicaid expanded beyond its roots as a welfare program. In 1987, Congress added coverage for pregnant women and children living in families with incomes nearly twice the federal poverty level (about $49,200 today for a family of four).

In 1997, Congress added the Children’s Health Insurance Program to help cover kids from families whose incomes are too high for Medicaid.

And since September 2013, Obamacare has allowed states to expand the program to anyone earning under 138 percent of poverty (or $16,394 for an individual in 2016), adding 17 million people to Medicaid’s rolls.

In addition, more than 11 million Medicare beneficiaries also receive Medicaid coverage, which helps them get long-term care and pay for Medicare premiums.

“Medicaid is plugging the holes in our health system,” says Joan Alker, executive director of the Georgetown University Center for Children and Families, “and our health system has a lot of holes.”

But that approach comes at a steep price.

A blessing and a curse

With increasing enrollments and health costs steadily rising, the cost of Medicaid has soared, too. Federal and state governments spent about $575 billion combined on Medicaid last year — nearly triple the level in 2000.

Those dollars have become both a blessing and a curse for states.

The federal government matches state Medicaid spending with funds from Washington, paying from half to 74 percent of a state’s costs in 2016. Poorer states get the higher shares.

The funding is provided on an open-ended basis, so the more states spend, the more they receive from Washington. That guarantee protects states when they have sudden enrollment spikes because of downturns in the economy, health emergencies such as the opioid crisis or natural disasters such as Hurricane Katrina.

The program is the largest source of federal funding to states. And Medicaid is often the biggest program in state budgets, after public education.

“Medicaid is the elephant in the room for health care,” says Jameson Taylor, vice president for policy for the Mississippi Center for Public Policy, a free-market think tank. He says states have become dependent on the federal funding to help fill their state budget coffers. While the poorest states, such as Mississippi, get a higher percentage of federal Medicaid dollars, that still often isn’t enough to keep up with health care costs, he says.

Extensive benefits

Medicaid provides significant financing for hospitals, community health centers, physicians, nursing homes and jobs in the health care sector.

But the revenue stream flows further. Billions in annual Medicaid spending goes to U.S. schools to pay for nurses; physical, occupational and speech therapists; and school-based screenings and treatment for children from low-income families, as well as for wheelchairs and buses to transport kids with special needs.

Medicaid also covers services that private health insurers and Medicare do not — such as nonemergency transportation to medical appointments, vision care and dental care. To help people with disabilities stay out of expensive nursing homes, Medicaid pays for renovations to their homes, such as wheelchair ramps, and for personal care aides.

Rena Schrager, 42, of Jupiter, Fla., who has severe vision problems, has relied on Medicaid for more than 20 years. Although she often has difficulty finding doctors who will accept Medicaid’s reimbursements — which are often lower than those from private insurance or Medicare — she is grateful for the coverage. “When you do not have anything else, you are glad to have anything,” Schrager says.

As it has grown, Medicaid has become more popular — another reason why politicians are cautious to curtail benefits or spending.

A recent survey by the Kaiser Family Foundation indicated that about 75 percent of the public, including majorities of Democrats (84 percent) and Republicans (61 percent), hold a favorable view of Medicaid. That is nearly as high as favorable views on Medicare. (Kaiser Health News is an editorially independent program of the foundation.)

Nonetheless, Medicaid may still have a bull’s-eye on its back.

“The fact that the House passed a bill to cut $800 billion from Medicaid and it came one vote short to passing the Senate shows Medicaid is stronger than maybe many Republican leaders anticipated,” says Oberlander. “But politically, it is still in a precarious position.”

Kaiser Health News is an editorially independent program of the Kaiser Family Foundation. This story launches “Medicaid Nation” — KHN’s series on how Medicaid affects the lives of millions of Americans.

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John McCain on Friday imperiled Republicans’ latest Affordable Care Act repeal and replace effort when he said he “cannot in good conscience” support the so-called Graham-Cassidy bill. But McCain did also say he could at some point support the substance of his fellow Republicans’ proposal.

“I would consider supporting legislation similar to that offered by my friends Sens. [Lindsey] Graham and [Bill] Cassidy were it the product of extensive hearings, debate and amendment,” McCain said. “But that has not been the case.”

That’s notable because for the first time since Trump became president, there actually seemed to be some real ideological unity around a repeal-and-replace effort from Republicans.

If it is revived — and this effort isn’t quite dead yet, because other GOP holdouts haven’t stated their unequivocal opposition publicly — the Graham-Cassidy bill very well may be the foundation of how the health care system is reshaped.

What would it mean for where you live? We take a look

A big selling point of Graham-Cassidy, according to its proponents, is flexibility for states. In place of the federal dollars that fund Obamacare’s subsidies and Medicaid expansion, Graham-Cassidy, which under the latest GOP proposal would be law in 2020, would give states block grants.

Those are big chunks of money given directly to states, which would have broad discretion in how to spend them.

But what’s important is that those block grants would be less money than the total money that states are getting for Obamacare right now.

Graham-Cassidy would eliminate the premiums that help people pay for their health insurance and the payments helping insurance companies keep prices down, and it would also take away the Medicaid expansion created under Obamacare. States that took this expansion were able to provide Medicaid to people earning up to 138 percent of the federal poverty level.

That would disappear, with the block grants taking that money’s place.

One section of the Graham-Cassidy bill spells out how the states can use the money — to help high-risk people buy insurance, for example, or to replace the premium subsidies to some degree.

One other thing the bill’s architects envisioned is a decline in spending. Altogether, the block grants would reduce federal government spending by $107 billion from 2020 through 2026, according to an analysis from the Kaiser Family Foundation. The left-leaning Center for Budget and Policy Priorities puts that figure even higher, at $243 billion.

And in general, states that took the Medicaid expansion would lose out, while states that didn’t take it would temporarily end up with more money. (However, Graham-Cassidy doesn’t allocate block grant money past 2026.)

The idea is that while the block grants are smaller, states can do whatever they like with them — and, ideally, what they do will be more efficient than what they’re doing now.

NPR reached out to the offices of both Graham and Cassidy to ask what they think would be optimal ways to spend the money, but has yet to receive a response. So we asked experts.

What might really happen

Given those basics — less money but more flexibility with that money — states would have big choices to make. And analyses have shown that Graham-Cassidy would leave millions — even tens of millions — more Americans uninsured than under the status quo.

“You can inject the money wherever you want into the problem of the uninsured, but if there’s less money you’re going to cover fewer people. There’s no two ways about it,” said Nicholas Bagley, a professor and health law expert at the University of Michigan Law School. “Or you’re going to cover as many people but less generously.”

So here are a few routes states could take, according to what a variety of health care experts told NPR. Given all the flexibility states might have, this is just a sampling of what states could do, but it’s a start at conceptualizing how health care in any given state might look if the bill passes.

Focus on demographics. “What is the patient mix? What does the consumer mix look like in your state?” said Lanhee Chen, research fellow at Stanford’s right-leaning Hoover Institution and policy director for Mitt Romney’s 2012 presidential bid. “Those are going to be important factors: demographic factors; patient mix and acuity; is there one dominant employer in the state?”

For example, a state with a large population of Medicaid recipients may want to direct more funding to helping lower-income people. Some states may also allow insurers to charge more for people with pre-existing conditions, meaning those patients may need more help.

Chen used Massachusetts as another example of how a state might decide to reconfigure its health programs.

“The average income is higher; you have people with more educational attainment who are used to making choices on a broad variety of things, where maybe more health care choices would not be problematic,” he said.

Boost Medicaid as much as possible. Some analyses have shown that Medicaid covers people for far less than it might cost under private insurance. With that in mind, says one expert, states might do well to just expand Medicaid as much as they can.

“If you wanted to do right for the health of the people in your state what would you do?” asks Amitabh Chandra, professor of social policy at Harvard University. To him, the answer is obvious: “The single most cost-effective thing to do is spend on the Medicaid program. It’s unbelievably lean, but it’s unbelievably efficient in terms of the value it delivers.”

… Or not. On the flip side, a state where lawmakers want less government involvement in health care could take a different route.

“A state could say, ‘We don’t really like putting the Medicaid expansion population back into Medicaid so what we’re going to do instead is help them get private coverage,’ ” said Bagley.

States could also make Medicaid less generous.

“In our Medicaid program in Ohio, we probably spend as much money now on optional benefits as we do on mandatory benefits,” said John Corlett, that state’s former Medicaid director. “People forget that a lot of benefits that states provide in the Medicaid program are optional.”

That could save a lot of money, he said, but he added a caveat: “That’s not making the program more efficient.”

Help clinics that serve low-income people. As low-income Americans would be the most affected by reduced premium subsidies and shrinking the Medicaid program, one expert says it would be smart to simply direct the money to places that serve the most low-income patients.

“Your choices are just awful,” cautions Sara Rosenbaum, professor of health law and policy at George Washington University — she believes that reducing money available to states both in the block grant and in Medicaid will force lawmakers to leave many of their constituents worse off.

“But the most sensible thing to do would probably be — at least where they’re available — to go to your public hospital or your community hospital or community health centers, and if you have other clinics in the region that see low-income people, to give them some grants and let them care for as many people as they can.”

Shift money toward (or away from) particular groups. A state may decide to move money currently used for insurance premiums down the income spectrum, Chen said.

“The ACA subsidy structure allocates subsidies for people making up to 400 percent of federal poverty,” he said, noting that that comes out to nearly $100,000 for a family of four. “A state like Kansas, for example — they might have a relatively smaller distribution of people that are at that income level, and by the way, most of those people might already be getting offers of health insurance” from their employers, he said (though it’s important to note Graham-Cassidy would also eliminate the employer mandate).

States could “beef up support for people making less than 250 percent of poverty,” he said. “That is something you could pursue under Graham-Cassidy that you couldn’t pursue under the ACA.”

This is contingent upon there being enough money, though, because once again, Graham-Cassidy would reduce federal funds to many states.

Move toward single-payer? Yes, it’s a Republican bill, but it grants a lot of leeway … meaning states could use their block grants to move closer to a single-payer system.

“Some states are going to experiment with how they bring more centralization into their marketplace,” said Chen. He hesitated to say single-payer — “I don’t know if there’s enough here resource-wise to make that work” — but he noted that a state might decide to create “some kind of a Medicaid buy-in system.”

Bagley explained how this sort of system might work.

“One alternative would be to take the money and create a state-based Medicaid-type program that paid Medicaid rates and have a Medicaid-type plan cover all the uninsured in the state,” said Bagley. “So it wouldn’t be single-payer, but it would be a single-payer approach for the uninsured.”

For this reason, some Republicans remain displeased with Graham-Cassidy. Louisiana Sen. John Kennedy this week said he was undecided on the bill for this reason.

“If you give California and New York a big chunk of money they’re gonna set up a single-payer system. And I wanna prevent that,” he said, as reported by Bloomberg’s Sahil Kapur.

However, GOP senators remain divided; Wyoming’s John Barrasso responded, “Either you believe in states’ rights or you don’t believe in states’ rights.”

Spend on something else. Or states may use the money in a way the bill totally does not intend: that is, for things that are totally unrelated to health care.

Though it’s true Graham-Cassidy specifies ways in which states must use the money, the bill does not stop states from simply using the federal money to take the place of other state spending.

“It’s just so much money, and block grants have a way of being pretty fungible, and states and others will figure out ways to divert these moneys to other purposes if they want to,” said Corlett.

Chandra elaborated on the kinds of choices states could find themselves making.

“I can maybe say I really like the exchanges in Obamacare, and I’m going to subsidize the exchange premiums,” Chandra elaborated. “Or I could decide to build a brand-new football stadium. That’s the degree of latitude we’re giving states.”

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Many older Americans who have Affordable Care Act insurance policies are going to miss a Sept. 30 deadline to enroll in Medicare, and they need more time to make the change, advocates say.

A lifetime of late enrollment penalties typically await people who don’t sign up for Medicare Part B, which covers doctor visits and other outpatient services, when they first become eligible at age 65. That includes people who mistakenly thought that because they had insurance through the ACA marketplaces, they didn’t need to enroll in Medicare.

Earlier this year, Medicare officials offered to waivepenalties for the ACA insurance buyers under a temporary rule change that ends Sept. 30.

On Wednesday, more than 40 groups, including insurers and consumer health advocacy organizations, asked Medicare chief Seema Verma to extend the waiver deadline through at least Dec. 31 because they are worried that many people are still unaware of the problem.

They also say more time is needed because some beneficiaries are experiencing delays at local Social Security Administration offices where they go to request the waivers.

“We know there are people who can still benefit from it [the waiver],” says Stacy Sanders, the federal policy director at the Medicare Rights Center, a Washington-based advocacy group that coordinated the request to Medicare. “We know there have been delays, and those are good reasons to extend it.”

Counselors at the Medicare Rights Center have helped seniors apply for the waiver in Arizona, California, Florida, Minnesota, Missouri, New Jersey, and New York, she says.

Since the marketplaces opened in 2014, the focus has been on getting people enrolled, Sanders says. “There’s no reason to expect that people would understand how to move out of the marketplace into Medicare.”

The waiver offer applies not only to people over 65 who have kept their marketplace plans, but also to younger people who qualify for Medicare through a disability and chose to use marketplace plans.

The waiver also allows Medicare beneficiaries who had earlier realized their mistake in keeping a marketplace plan to ask for a reduction or elimination of the penalty.

In addition, the waiver is only available to people eligible for Medicare after April 1, 2013.

Officials at the Centers for Medicare and Medicaid Services would not provide details about the number of waivers granted or pending applications.

Barbara Davis, 68, says that when she initially applied, a Social Security representative didn’t know about the waiver. She eventually contacted the Medicare Rights Center, where a counselor interceded on her behalf in June. A day later, a Social Security representative told her she would not face a penalty.

“My advice would be, find out your rights before you apply,” says Davis, who lives with her husband in rural western New York. “Because they don’t seem to want to give you information to help you, you have to know this on your own.”

A Social Security spokeswoman says the agency is processing waiver applications from “across the country” but does not keep track of the number. She declined to comment on whether SSA employees know about the waiver.

Sanders suggests that people applying for the waiver ask Social Security officials for it by using its official name: “time-limited equitable relief.”

It’s easy to see how people can make mistakes. Since Medicare’s Part A hospitalization benefit is usually free, some seniors who liked their marketplace coverage thought incorrectly that they had nothing to lose by signing up for Part A and keeping their marketplace plan.

Other people receiving Social Security retirement or disability benefits opted to keep their marketplace plan and drop Part B after the Social Security Administration enrolled them automatically in Medicare when they became eligible.

If beneficiaries miss the Sept. 30 deadline, the only other way for them to get out of penalties is by proving they declined Part B because a government employee misinformed them.

The groups writing Verma argue that keeping the penalty waiverin place longer could also help many beneficiarieswho may be surprised by a little-known rule that will affect 2018 marketplace policies.

For the first time, insurers will be prohibited from issuing a marketplace plan if they know the member is eligible for Medicare and the 2018 policy is significantly different.

Those who find themselves without a marketplace plan could be in for another surprise: They won’t have insurance for outpatient care until July 1 because Medicare imposes a waiting period before Part B coverage kicks in for latecomers.

Extending the deadline “would lessen a significant hardship for many people … because they are unaware of the repercussions that could result from keeping their marketplace coverage,” says Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry group.

For information on how to apply for the time-limited equitable relief waiver, go to the Medicare Rights Center’s Medicare Interactive webpage or call the center’s helpline at 1-800-333-4114.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.Find KHN’s Susan Jaffe on Twitter @SusanJaffe

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