PPACA cut Valerie Dalton's monthly health insurance bill to $360, from $700.

(Bloomberg Politics) — In Georgia’s Gwinnett County where Republicans rule, few really love “Obamacare.” Few want to lose it either.

In parts of the county, about 1 in 8 people get insurance from the federal health care program, making Gwinnett, near Atlanta, one of the biggest per capita users of the Patient Protection and Affordable Care Act (PPACA). The coverage is advertised in road signs along busy Jimmy Carter Boulevard near Lilburn. It’s the reason enrollment has dropped at low-cost clinics in Snellville and Norcross. It’s seeped into the Asian, Latino and African immigrant communities, becoming a mainstay for retail workers, contractors and the downsized.

See also: Poll: Americans want Supreme Court to leave PPACA subsidies alone

As the U.S. Supreme Court prepares to rule on a case that could make PPACA’s private insurance unaffordable in Georgia and at least 33 other states, Gwinnett, where all five of the county commissioners belong to the Republican Party that has been leading the fight against the health care law, illustrates how for many the program has become a fact of life. PPACA is both groused about and accepted, like taxes and the weather.

“I couldn’t buy insurance for myself after my husband retired, not until PPACA,” said Ghada Nadhan, 63, an assistant manager of a food store who immigrated from Syria more than two decades ago. “Now I am afraid.”

Now before the Supreme Court, the King vs. Burwell case threatens to make PPACA unaffordable by ending federal subsidies that hold down premium costs based on income. A suit backed by conservative activists, citing a single phrase in the law, says those subsidies aren’t allowed in states that didn’t create their own health care exchanges.

Undermining PPACA

Led by the free-market Cato Institute, those opponents helped persuade Republican governors not to form state-run exchanges, as a tactic for undermining PPACA.

See also: GOP unveils plan to replace PPACA

More than 13 million Americans could lose tax credits that help pay for insurance coverage by next year, according to the Kaiser Family Foundation. Florida, Texas, North Carolina and Georgia, the states with the most to lose, received a combined $19 billion, according to a December report by Democratic staff of the House Energy and Commerce Committee.

All four states declined to create exchanges and could have spiraling premium increases if the court nixes their subsidies. In Georgia, premiums would rise 381 percent without the credits, according to a June 3 analysis by Kaiser.

“It’s not something that should be done based on a twisted interpretation of four words in, as we were reminded repeatedly, a couple-thousand-page piece of legislation,” President Barack Obama said Monday at a news briefing in Germany. “Part of what’s bizarre about this whole thing is we haven’t had a lot of conversation about the horrors of Obamacare because none of them have come to pass.”

See also: GOP swiftly rejects Obama’s ‘one-sentence fix’ to PPACA if Supreme Court voids subsidies

In Gwinnett, attitudes about PPACA depend a lot on subsidies, said Luis De La Rosa, an insurance salesman who advertises in a Hispanic part of Lilburn. He says ending the federal help would be a disaster.

“The people who say it doesn’t work now are the people who aren’t getting the subsidies and facing fines if they don’t enroll,” he said.

They’re also people who aren’t sick, he said.

“That’s an advantage people forget. Before, you couldn’t get insurance if you were sick.”

Gwinnett is a microcosm of a changing nation. Once overwhelmingly white, it’s now one of the most ethnically diverse counties in the U.S., largely because of its immigrant population. It had 73,839 people enrolled in PPACA’s insurance exchange as of May, the most in the state. Two Gwinnett zip codes had 12 percent of residents enrolled in PPACA, the most outside of Florida.

PPACA has had the biggest impact on the area’s low-cost medical facilities. At Gwinnett Community Clinic in Snellville, staff began calling former patients this year after a 30 percent enrollment drop.

“The reason they were gone is that they now had insurance,” director Sheila Adcock said.

The same thing happened in Norcross, at a clinic run by Boat People SOS. Daily caseloads dropped to 10 from 20 after the organization helped enroll immigrants in PPACA, said Han Nguyen, a health navigator.

Even enrollees with generous subsidies have complaints, said Adcock, who heard some during her phone outreach.

“If you are a person in poverty, you’re not used to the idea of co-pays and deductibles, and you’re wondering what you are paying for,” she said.

Precarious premiums

Charles Pierre, 58, a Haitian immigrant and substitute teacher, was among those signed up by Nguyen. He said his subsidized premium has already almost doubled, to $45 a month from $23, and that he also has a $35 co-pay to see a doctor.

Pierre said he likes the security the insurance brings but would have to drop it if the subsidy disappears and the price goes up again.

“It’s going to be a struggle for me to pay for it,” he said. “What I earn is not changed.”

Valerie Dalton, 64, got her PPACA insurance in February, after her banking job was eliminated and she could no longer afford the $700 monthly price to stay on her former employer’s plan.

She said her PPACA premiums are about $360 per month, a price she still thinks is high but that she won’t have to pay for long. Next month she’ll turn 65 and be eligible for Medicare.

“I’m not politically active at all, but I feel badly that they are threatening this,” she said. “I think it’s really sad.”

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