John Nehls has learned to be resilient. Nearly three years ago he crashed into a truck riding his bicycle less than a mile from his home in Knoxville, Tennessee.
"The force telescoped through my back and burst three vertebrae," leaving him wheelchair bound Nehls said.
Now he's facing another health care challenge. He and his wife are self-employed and rely on their Obamacare plan to cover his medical needs.
"The biggest concern we have is what's going to happen in 2018. We do have coverage for this year on the Humana plan, but in 2018 there will be zero options in this county, " he explained.
Humana is the only insurer offering exchange plans this year in Knoxville and much of eastern Tennessee, but in February the insurer announced it would be dropping out of the Obamacare market in 2018.
More than half of the state's Obamacare enrollees receive cost-sharing subsidies that reduce out of pocket costs, but the Trump administration and Congress have not given insurers a firm commitment that they'll continue funding the so-called CSR payments.
"The most critical issue for us is funding the cost-sharing reduction payments," explained Julie Mix McPeak, Tennesee's commissioner of the state's department of commerce and insurance.
Without clarity on the CSRs soon, McPeak says the coverage crisis facing east Tennessee will spread. Even though insurers have indicated a willingness to offer plans in the state with early filing deadlines like Kentucky and Virginia, they don't have to commit for 2018 until next September.
"We have five states that only have one insurer statewide and another 9 like Tennessee that have a majority of counties having only one insurer offering coverage. And I think the lack of funding for the CSR payments would be a blow to those markets," she said.
Tennessee's Republican Senators, Lamar Alexander and Bob Corker, have proposed a stop-gap measure that would allow residents in Knoxville and other communities to exchange tax credits to buy off-exchanges plans if they have no Obamacare coverage.
That could allow some residents to buy plans from the Tennessee Farm Bureau in the private individual market, but the industry association's health plans may not be an option for enrollees with pre-existing conditions.
"The Farm Bureau plans... have tens of thousands of consumers, all of whom are healthy because they have passed the health screening that the Farm Bureau is allowed to require," said Sabrina Corlette, research professor at the Center on Health Insurance Reforms (CHIR) at Georgetown University. "The plans that are in the ACA marketplaces aren't allowed to do that."
As Congress gets ready to take up the battle over the GOP health plan again in Washington, anxiety and frustrations are high in Knoxville.
Area clinics like Cherokee Health Systems are seeing increased demand or preventive screening procedures, such as mammograms and colonoscopies, from patients worried they will lose insurance coverage at year's end.
"The lack of clarity, the changing every single day, in a way makes it harder, because one minute you are ready to deal with one plan, and then literally two hours later or even the next day, there could be a different proposal," said Parinda Khatri, Cherokee Health's chief clinical officer.
Many here, like John and Cheryl Nehls feel like Washington just doesn't get it.
"Do they realize what type of pressure that you face every day in making health care decisions?" asked Cheryl Nehls.
"It's confusing and scary," John Nehls said. "Simply waiting to let the current law explode is going to leave a lot of people hurt."
And the longer the debate in Washington goes on, the higher the number of people in communities like this that could fee the pain.
—By Bertha Coombs. Follow her on Twitter: @coombscnbc
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