PRINCETON, Ill. - Commuting past the barren winter fields in northern Illinois, Cathie Chapman worries about the future.
More than a year ago, she lost her job at a nearby rural hospital after it closed and, as Republicans work to dismantle the Affordable Care Act, wonders whether she'll soon be out of work again.
"Many of my friends did not find jobs they love," she said. "They're working for less money or only part time. Some haven't found any jobs yet, even after a year."
Now she runs the pharmacy at Perry Memorial Hospital here, warily watching the Republicans' repeal efforts.
"I think everybody who works in health care now feels a little uneasy," said Chapman. "We don't know what's coming around the corner, and how it will affect us. But we know that change is happening so fast, it is exhausting and difficult to keep up with."
Rural hospitals have long struggled to stay open. They have far fewer patients and thin profit margins. Dozens have closed across the country in recent years, mostly in states that didn't expand Medicaid.
But in Illinois, which did extend Medicaid to nearly all poor adults, patients at Perry Memorial have gained coverage under the Affordable Care Act and many hospitals have found firmer footing.
If large numbers of people lose their insurance under the Republicans' replacement, the hospital's finances - and those of its patients - would be at risk, especially after the hospital invested so much money and time in complying with the health law, said chief executive Annette Schnabel.
"We have spent the last six years gearing up towards everything that we were responsible for doing in the ACA," Schnabel said. If the hospital has to "totally go a different direction, how will we do that? It's going to take a lot of work."
And for some hospitals to survive or break even, it would require Congress to restore billions of dollars in funding that kept hospitals afloat before the 2010 law took effect.
Hospitals across the country made a high-stakes trade when they signed on to the Affordable Care Act. They agreed to massive cuts in federal aid that defrayed the cost of caring for the uninsured. In exchange, they would gain tens of millions of newly insured customers. Now that deal is in jeopardy, and many hospital executives anxiously await whatever comes next.
In Chicago, John H. Stroger Jr. Hospital of Cook County is among the nation's busiest hospitals, handling most of the city's gunshot victims. The vast majority of its patients used to be uninsured, and the county-run hospital struggled to take care of their medical and mental health needs.
Those patients now have Medicaid coverage because of the Affordable Care Act, and the Cook County hospital system gained $200 million in new revenue to cover their services, breaking even for the first time.
"We have no interest in slipping back in what we've been able to do," said Dr. John Jay Shannon, chief executive of the Cook County Health and Hospitals System. "We're not able to do the kind of work that we do today with good will alone. Our staff are not a volunteer staff. We can't get IV fluids and medical equipment on credit and a wink and a nod."
Two hospital trade groups - the American Hospital Association and the Federation of American Hospitals - have warned of "an unprecedented public health crisis" if the law gets hastily scuttled.
They say if Congress repeals the law entirely and 20 million people are kicked off their insurance, hospitals will lose $166 billion in Medicaid payments alone in the next decade.
And hospitals face much steeper losses if certain Medicare cuts that were part of the law aren't restored.