Troy Anne Cada closes the gate to Silverstage Food Pantry after a day of serving low-income residents of Silver Springs, Nev. (Melina Mara/The Washington Post)

In this speck of high desert, along a stretch of highway that Life magazine once called the loneliest road in America, the only doctor in town comes just one day a week. In the past few years, though, health insurance has arrived in force.

The county that includes Silver Springs now has more than 3,500 additional residents on Medicaid, because Nevada’s governor was the first Republican in the country to expand the program through the Affordable Care Act. Nearly 1,400 others have private plans through the law and the Silver State Health Insurance Exchange.

Incomplete as it is, with many still falling through the cracks, such progress encouraged the health system that runs a little outpost in town to invest here in long-distance medicine. The new coverage has paid for back surgeries and brain surgeries for people who otherwise would have been left broke or unhealed.

Yet 2,600 miles away, what Congress is now doing — or not doing — imperils these two strands of insurance that lately have cut Nevada’s uninsured population by half. Republican lawmakers would start to erase the money that props up Medicaid’s expansion. And even with a GOP health-care plan teetering in the Senate, months of uncertainty about the ACA’s future have heightened insurers’ qualms in Nevada about whether its marketplace is a financially safe space to be.

The sole company that had been expected to remain on the state exchange in Lyon County and Nevada’s 13 other rural counties announced otherwise last month and will be gone by January. Unless Anthem or another insurer reverses course, 8,000 people across hundreds of miles will be left without any ACA insurer next year — by far the largest such bare patch in the nation.

“In a place where health care was already a disaster,” said Shaun Griffin, a local poet and community activist, “it’s criminal that this is happening.”

The stakes in this land of dusty winds and scarce jobs attest to the special vulnerability of rural communities to the health-care politics of Washington. The toehold that insurance has gained, even here in strong Trump country, suggests why Nevada Sen. Dean Heller became an early, overt critic of what his Republican Party leaders want to do. It also explains why even sustained pressure from the White House has not altered Gov. Brian Sandoval’s opposition to the Senate’s bill.

Robert Garcia practices his roping skills every evening outside his mobile home in Silver Springs, Nev. Garcia competed in rodeos until he was thrown from a horse a few years ago. Not until he got onto Medicaid was he able to have back surgery for the injury. (Melina Mara/The Washington Post)

In Silver Springs, where finding medical care is iffy in the best of circumstances, an insurance card isn’t a guarantee. But it is a leg up.

Robert Garcia was living in his horse trailer with three crushed discs in his back when a county caseworker told him that, because the state’s rules had changed with the ACA, he could get onto Medicaid.

Garcia used to earn about $50,000 a year doing electrical work at a nearby gypsum mine. He lost his insurance when he was laid off in 2011. His marriage fell apart. Rodeo had been his passion since he was a boy, and he moved into the trailer, filled with championship buckles and saddles, that carried him and his horses to competitions. It had a generator for electricity, and Garcia parked it on different friends’ land, taking showers from hoses outside in the dark.

He picked up money by breaking horses until the day a young mustang with a fiery spirit got spooked and lurched, throwing the cowboy off its left side. He landed on his neck. Despite the pain, he kept riding and roping for another month before paying for an X-ray. He couldn’t afford the surgery he needed.

In 2015, a woman at the local food pantry took him to the county’s health and human services branch in Silver Springs. There he got onto Medicaid. After more rounds of doctors, he had surgery last year at a Reno hospital.

But in the kind of seesawing scraping-by that is common here, the Social Security disability benefits for which Garcia was finally approved in April meant he could afford to rent a mobile home. But he no longer qualified for Medicaid — which meant no return to the doctor to see whether he could get back on a horse. At 50, with a bad knee, fingers still numb from the fall and anxiety, he now is waiting on a health plan through the state exchange. The coverage may be fleeting.

“That would devastate me,” he said. “I don’t know what I would do.”

‘Sign me up’

Local residents wait to be checked in at the Silver Stage Food Pantry, which also offers periodic health education and screenings. (Melina Mara/The Washington Post)

Straddling U.S. Route 50 in a mountain-ringed valley studded with saltbush, Silver Springs sits about an hour from the neon of Reno and even less from the state capitol building in Carson City. It is not as remote as Nevada’s huge frontier counties, where the nearest hospital can be hours away.

Still, it is rural enough that Bret Bellard, the family doctor who works at Renown Health’s clinic on Mondays, sees patients bitten by their donkey or kicked by their goat, along with diabetes and addictions. Wild horses run through the clinic’s parking lot.

The area’s big moments were during the Pony Express and gold rush days. Today, the economic glitter of a Tesla Gigafactory under construction less than an hour away has stoked hopes that good jobs might spill down a road being built from Route 50.

They are pipe dreams for now. The Silver Strike Casino and a Nugget Casino branch each offer some jobs. So do a Family Dollar and Dollar General, the only stores. With no local grocery, the two gas stations’ food marts are the only places to buy even a carton of milk; the Silver Stage Food Pantry, which serves the town and tinier Stagecoach just to the west, is trying to foster community gardening.

Wild horses graze between the two casinos along U.S. Route 50 in Silver Springs. (Melina Mara/The Washington Post)

In this environment, the cinder block clinic that had been here for decades called it quits during the Great Recession. Renown, a Reno-based nonprofit, took over in 2008 and managed to get it federally certified as a rural health clinic. Since attracting health-care professionals to the area is hard, the designation means a young nurse practitioner and a physician assistant can work to help repay student loans. This year, Renown installed a telehealth system so that patients with bad hearts or troubled mental health, for example, can sit in an exam room and talk with a doctor via a computer screen.

The federal label also allows the clinic the luxury of seeing any patient who can get an appointment, no matter how much they can pay. But Renown’s president, Anthony Slonim, is pragmatic about what could happen if the Senate Republicans’ Better Care Reconciliation Act became law. “None of us are making money in the rural environment, trust me,” Slonim said. “If more people become uninsured, expenses will go up and revenue will go down. . . . It gets increasingly challenging for us to sustain those practices. People’s care will suffer.”

The scarcity of health services dovetails with an individualistic streak that has long coursed through the West. Yet even the most independent at times need help.

Tom Lovelace, who has a landscaping business in Silver Springs, didn’t vote in the last election. He says he doesn’t believe in government, though he thinks Trump is “cool.” He also doesn’t like the idea of health insurance — just take care of yourself or tough it out.

Still, Lovelace reflects the realities plumbed by a recent Washington Post-Kaiser Family Foundation survey, which found that most rural Americans consider Medicaid very important to their communities — including nearly three people in five who voted for Trump.

Tom Lovelace works on a new garden outside his mobile home in Silver Springs. He never knew he could get health coverage through Medicaid until after surgery for an aneurysm. He signed up despite his anti-government views. (Melina Mara/The Washington Post)

Rockie Rossberg, 4, is called in for dinner by her mother, Hoppie Rossberg, at their double wide mobile home and small ranch in Silver Springs, Nev. Hoppie Rossberg believes fewer Medicaid entitlements would be better for the economy and the country. (Melina Mara/The Washington Post)

The day after he turned 30 in 2014, Lovelace woke up at 4 a.m., sweaty, his speech slurred. He told his customers he thought he’d had a stroke. He was living in Carson City at the time, and, two weeks later, a friend took him to an emergency room. He got an MRI but left before finding out the results.

The next month, he had an awful headache one day and started to see double, then triple. When he went back to the emergency room, the doctor told him he was relieved to see him. He had an aneurysm, a weakened spot in a blood vessel in his brain. At Renown’s hospital in Reno, he had it repaired and — uninsured — received a $99,000 bill.

Nearly three months later, as Lovelace was signing up for food stamps, a worker at the welfare office asked whether he wanted to get Medicaid. He was surprised. He knew of it as help for his three kids — their names tattooed on his arms and chest — and their mothers. Not for a guy like him.

“Sign me up,” he replied. Medicaid retroactively paid his hospital bill.

In Dayton, Nev., Jenny Claypool lost Medicaid coverage after she got a small raise but was able to sign up for a health plan on the state insurance exchange. She worries that she’ll lose that, too, because her insurer is pulling out of the local market next year. (Melina Mara/The Washington Post)

‘Why do we have to change?’

On June 27, the governor sent a letter to all four insurers that have been selling health plans through the state’s ACA marketplace this year and are part of Nevada’s managed-care Medicaid in its urban areas. “The reduced footprint of carriers on the exchange,” Sandoval wrote, “is a national embarrassment for a state that has made great strides in reducing our uninsured population.” He asked them to “find a . . . solution.”

The governor and his chief of staff, for years Nevada’s health secretary, waited three days before Sandoval sent another letter saying he was “disappointed” in the insurers and summoning them to his office Tuesday to try to hammer out a plan.

The prospect of losing ACA coverage in every rural county is a reversal of fortune for a state whose embrace of the 2010 health-care law has brought dramatic results. Before the ACA, 23 percent of Nevadans were uninsured, one of the worst rates in the country. Today, it is 12 percent.

Mike Willden, the chief of staff, said officials are talking with the Trump administration about how much it can bend the ACA’s rules to ward off the exchange’s rural meltdown next year. Perhaps they could let people enroll in the health plans available in Reno and Las Vegas, though their doctors would be farther away. Perhaps the state’s four ACA regions could be collapsed into one, so that any insurer wanting to stay in the urban areas would have to sell health plans in the rural places, too. And a study is going to look at a novel strategy endorsed this spring by the legislature — letting any Nevadan pay to join a Medicaid health plan.

No one knows whether any of these ideas might work.

In the meantime, Sandoval, like Nevada’s senior U.S. senator, has been speaking out against what his fellow Republicans are trying to do in Washington. The state has documented ways the expanded insurance has improved residents’ well-being, especially in access to mental health care.

“If it is working in Nevada,” Willden asked, “why do we have to change?”

Over at the Silver State exchange, Executive Director Heather Korbulic is already worrying about what will happen this winter to people who suddenly may be without coverage in counties such as Lyon.

“It’s such a tenuous time,” she said. “It’s not that we are not trying. . . . But insurers in Nevada have been resistant to these rural counties for a very long time.”

Old cars, artifacts and more sit on a hillside in Dayton that locals call “The Yard.” (Melina Mara/The Washington Post)

It was the 5 p.m. news on KOLO-8 out of Reno that told Jenny Claypool her new health plan is going away next year.

“What!?” she exclaimed. Despite her job with a community health group and $350 in a monthly insurance subsidy through the ACA, Claypool relies on help from her 78-year-old mother in California to afford the $300 she still must pay in premiums every month. Only ACA coverage comes with subsidies.

Fifty-one and divorced for a decade, she lives in Dayton, a bit west of Silver Springs. She had insurance when she worked for the county school system, but then she changed jobs and went several years without any. Her mental health is fragile — bipolar and borderline personality disorder. During one bad spell, she went to an emergency room in Carson City, which transferred her to a state hospital.

When Claypool heard in 2014 that Medicaid was expanding, she signed up right away, started therapy and began filling her prescriptions at the pharmacy inside the Smith’s grocery store in Dayton, just like anyone else. Last year, Medicaid paid for surgery to repair a tear in her hip. Last fall, she became ineligible for the program after she got a raise at work that lifted her pay from $15 an hour to $17. She turned to the exchange, picking a health plan called Anthem Silver Pathway. The plan will be gone Jan. 1.

That coverage “is a huge sense of security,” Claypool said. “I am going to be out there with nothing.”