Sorting out the way forward is agonizingly complex. Kentucky’s Medicaid expansion and successes under the Affordable Care Act are largely the result of former Gov. Steve Beshear, a Democrat who is out of office now. Meanwhile, Gov. Matt Bevin, a Republican elected in 2015, is pushing for a Medicaid waiver from the federal government that includes requirements for many beneficiaries to work or participate in job training.

Dr. Van Breeding, the clinic’s director of medical affairs, lamented that the Republican bill in the Senate had gotten mixed up in “party politics,” while patients had been forgotten. He summed up the situation this way: “Senator Paul is worried about the financial aspect of it. Senator McConnell is worried about the political aspect of it. And I’m worried about patients not having access to basic health care.”

Kathy Collins, 50, who suffers from lupus, an autoimmune disease — and who was uninsured until she got Medicaid coverage through the law’s expansion — is among Dr. Breeding’s patients. Sitting in her hospital bed here Tuesday morning, she said she was surprised to hear that Mr. McConnell, whom she had voted for previously, was leading the charge to roll it back.

“He is?” she asked. “Well, then, he’s no good for Kentucky.”

Health care is a growing part of this region’s economy, and people here are also deeply concerned that the repeal will bring job losses to a region already decimated by unemployment from the coal industry downturn.

Dr. Breeding says the number of uninsured patients at the clinic dropped from 19 percent to 4 percent as a result of the health care law. He said Mountain Comprehensive was “barely getting by” financially before the law was passed; business is much better now. Mountain Comprehensive has hired more people and now offers extended weekend hours and an optometry clinic — services that have been financed by revenue brought in from the health law, Dr. Breeding said.

And those services mean more health care jobs.

“If they do what they say they are going to do, then we may lose our jobs,” said Vicki Roland, a surgical nurse. “I think what we have works pretty good for the people. If they revamp it, I’m not sure what’s going to happen.”

Mr. McConnell’s office did not respond to a request for an interview. But Mr. McConnell did make his case for why the bill would help Kentucky on the Senate floor last week, and in an opinion piece in The Cincinnati Enquirer on Sunday, in which he argued that the legislation would stabilize markets and “deliver flexibility” to state officials to address problems like the opioid crisis.