Sarah Ashby is afraid of what may happen if the Affordable Care Act (ACA) would disappear, saying the effects on her would be devastating.


The 25-year-old Iowa State University student suffers from mental illness that requires medication and therapy. Being under the age of 26, she’s still on her parent’s health insurance because of the ACA. If that were to be taken away, her monthly costs would jump from $56 to $1,200.


“The thought that my insurance could be stripped, well, that’s terrifying,” Ashby said.


Ashby is one of more than 51,000 people in Iowa who would lose their health insurance if the ACA, commonly called Obamacare, would be completely repealed. The burden for their care would then fall on unpaid emergency room visits at local hospitals, and free clinics, officials at those facilities say.


“There is no way the clinic could handle such a huge increase,” said Dr. Eric Peterson, a physician at the Boone County Hospital who runs the county’s free clinic.


In Boone County, 1,530 people are covered by the ACA, a proportionately large number considering the county accounts for 3 percent of the state’s residents on the ACA, but for less than 1 percent of the overall population.


The first six month’s of President Donald Trump’s term have revolved around repeated and narrowly failed attempts to repeal Obamacare.


The Republican-controlled Senate’s most recent attempt to repeal smaller sections of the ACA, dubbed a “skinny repeal,” in late July was just three votes shy of passing, leaving Obamacare supporters without much to celebrate as the fear of repeal is still real.


“We are not celebrating, we are relieved, that millions and millions of people … will at least retain their healthcare,” said a tearful Senate Minority Leader Chuck Schumer following that vote.


The “millions and millions” of people number Schumer referred to is found within reports from the Centers for Medicare and Medicaid Services (CMS), the federal agency within the United States Department of Health and Human Services, that administers the Medicare and Medicaid programs and oversees HealthCare.gov, the health insurance exchange website created under the ACA. The numbers indicate that around 24 million people in the U.S. would lose health insurance if the ACA were to be completely repealed.


In Iowa, Polk County stands to take the biggest hit because it makes up half of the people in Iowa enrolled under the ACA at nearly 26,000 people. However, Polk County also makes up 14 percent of the state’s total population, meaning services such as free clinics are more accessible.


“If the Affordable Care Act was repealed, taking on the role of caring for those who would lose insurance would be incredibly hard,” said Tess Young, the manager of St. Luke’s free clinic in Polk City. “They (the federal government) can’t just take it away. How do they expect people to just be fine?”


When asked if Polk County would be able to handle an extra 26,000 people in need of healthcare, Young said, “Well, we’ll give it our best shot.”


Handling an influx of people would be even more difficult for many other, smaller Iowa counties where services may not be as accessible. Polk County has eight free clinics. The only other county with more than one is Marion County, southeast of Des Moines, which has two. Only 20 of the 99 counties in the state even have a free clinic.


“It would really hit smaller hospitals like here in Boone harder than bigger areas, and our hospital is relatively well managed comparatively to other similarly sized hospitals,” Peterson said Peterson.


Free Clinics of Iowa Director Wendy Gray said before the ACA went into effect, 10 percent of Iowans were uninsured.


“We had 40-plus free clinics that had lines outside of the doors before the clinic even opened, and the reality is we may be there again,” Gray said.


Gray and other free clinic directors around the state agreed the ACA hasn’t done as much as they had hoped, but that it hasn’t been without benefit.


“Certainly, it wasn’t the drop-off (of people using free clinics) we had hoped for. We learned quickly that having an insurance card doesn’t equate to access,” Gray said. “Health insurance is still unaffordable for many, and reform is a necessity.”


Young, the manager of the free clinic in Polk City, agreed the clinic saw a decrease of free clinic users, and added that a lot of the services provided by the clinic changed.


“We tried to become more of a way to guide people on how to get insurance after the ACA was passed,” Young said.


Peterson, echoed a similar sentiment.


“Our numbers decreased after the ACA was passed, but we’ve seen a gradual increase in people who have been returning,” he said.


Much of the problem lies with those who have a serious illness, Peterson said.


“One of the proposals (the Senate recently proposed) would be to introduce policies that would be less expensive; however, those exclude pre-existing conditions,” he said. “So all the healthy people would gravitate towards cheaper plans, but eventually people with pre-existing conditions couldn’t afford what they needed.”


Free clinics are not set up to handle serious illnesses, leaving a lot of that burden on emergency rooms, Peterson said.


“So then hospitals are losing money, and they have to jack up the rates on everyone else, because sick people will wait until the last minute to get treated because they didn’t have insurance to deal with the problem when it was simple” he said. “It’s just going to end up with higher payments and taxes for everyone regardless of insurance status.”


Ashby said she anticipates having to go on Medicaid once she turns 26, because her illness prevents her from working full time, which could allow her to obtain insurance through an employer.


“I need the Medicaid expansion from the ACA to stay, because otherwise in order to get it, I would have to have a kid, and that’s just crazy,” Ashby said.


The Medicaid expansion under the ACA removed the requirement a woman have a child before she could receive the benefits from Medicaid.


The free clinic directors and doctors agreed the ACA needs to be improved, but said they are not seeing that in the proposals put forward by the government.


“Obviously, it wouldn’t be an issue if it (the ACA) was replaced with something better, but we’re not seeing that in what the Senate is trying to do,” Young said.


Peterson said the repeal of Obamacare without a better option would do more harm than good, and he would like to see Democrats and Republicans work together to address the real issues within the bill.


“To a certain degree, (the way the government is handling the healthcare debate) it says a lot about the way we treat the less fortunate,” Peterson said. “It says a lot about what kind of society we are and what kind of society we want to be.”