Darvin Bentlage’s health insurance plan used to be the same as all the other cattle farmers in Barton County, Mo., he said: to stay healthy until he turned 65, then get on Medicare. But when he turned 50, things did not go according to plan.

“Well, I had a couple of issues,” he said.

That’s putting it mildly.

Over two years, he dealt with hepatitis C and diverticulitis. That was on top of his persistent kidney stones, diabetes and other health problems.

“I had to go back and refinance the farm,” he said. “By the time the two years was up, I had run up between $70,000 and $100,000 in hospital bills.”

He does not want to end up in that situation again, so he is paying close attention to what Republican health care bill working its way through Congress might mean for him.

He racked up those medical bills in 2007. Bentlage said that given his preexisting conditions, health insurance became impossibly expensive — a problem because he needed more health care. So when the Affordable Care Act exchanges opened in 2013, he said, “I was probably one of the first ones to get online with it and walk through it.”

About a quarter of the people on the exchanges are between 55 and 64, and they have more health problems than younger people do. So they have a lot on the line if the Affordable Care Act gets replaced. Under the GOP plan, older people’s insurance cost could rise dramatically, but the subsidies would be capped at $4,000. That’s less than half of what Bentlage is getting now under the ACA.

“And my estimated income is less than $20,000. So I’d have to go back to Plan A and hope I make it to 65, you know?” he chuckled.

Insurance premiums tend to be higher in rural areas where the population tends to be older, poorer and sicker than elsewhere. And Maggie Elehwany of the National Rural Health Association said there’s another issue: 80 rural hospitals have closed across the country since 2010.

“We’ve got an access crisis going on,” she said. “What this House bill does is nothing — nothing to address the rural hospital closure crisis. You’ve got to understand that so much of that is linked to not only the health, but to the economic vitality of the community. If a hospital closes in a rural area, it closes for good.”

One reason for these hospital closures is that 19 states, including Missouri, chose not to expand Medicaid, which left poor rural patients uninsured. The GOP proposal would cut Medicaid more over time.

Bentlage said his county recently increased property taxes to keep its hospital open.

“It falls on the farmers,” he said. “My property tax on the hospital went from about $80 to about $400. And it’s still in trouble.”

Missouri’s Republican congressional delegation has said Obamacare has failed. And Bentlage, whose positive experience with the health law once was featured in a healthcare.gov video, said the ACA does need work.

“There’s problems with it,” he said, “but I don’t think it’s worth scrapping.” All you need to do, he said, is look at how it’s helped him.

This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News.