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BOSTON (AP) 鈥� In the state that served as the model for Obamacare, advocates and health care workers fear the Trump administration is trying to dismantle piece-by-piece a popular program that has provided insurance, preventive care and life-saving medication to hundreds of thousands of people.

Provisions contained in both the Senate and House versions of the massive tax and spending cuts bill advancing in Congress 鈥� a centerpiece of President Donald Trump鈥檚 agenda 鈥� could strip health insurance from up to a quarter of the roughly 400,000 people enrolled in the Massachusetts Health Connector, according to state estimates.

The changes would create anew the coverage gaps state leaders were working to close when Massachusetts in 2006 became the first U.S. state to enact a law requiring nearly every resident to have health insurance, state officials say. Beyond the effect on residents’ health, losing care could have broader repercussions 鈥� both for the program’s finances and residents’ ability to make a living.

鈥淭he idea of needing to unwind that now and pull back on that promise and commitment is really frustrating and heartbreaking and cruel and counterproductive,鈥� said Audrey Morse Gasteier, executive director of Massachusetts鈥� health insurance marketplace.

Trump and Republican supporters in Congress say the changes, which include new documentation requirements and limitations on who can apply for tax credits to help pay for insurance, are necessary to root out what they call fraud, waste and abuse. The Affordable Care Act changes proposed in both versions of the bill, along with massive cuts to Medicaid and other programs, would eliminate roughly $1.1 trillion in health care spending over the next decade, according to the nonpartisan Congressional Budget Office.

In Lawrence, a mill community of around 90,000 people on the Merrimack River, where more than 80% of the population is Hispanic or Latino, Kesia Moreta said she’s already seeing people slip out of the state’s health care network because of the Trump administration’s aggressive effort to crack down on illegal immigration.

Moreta, who manages a program created under the ACA that helps people sign up for coverage, said clients have been missing meetings out of fear that being enrolled for health insurance will harm their effort to stay in the U.S. legally.

Recently, a father of a U.S.-born teenage son with epilepsy deleted every email related to his health plan and stopped answering calls from the Connector after watching reports about deportations on social media. When his son鈥檚 medication ran out, Moreta said the father finally reached out, whispering over the phone, 鈥淚s this going to get me deported?鈥�

鈥淭hat breaks our hearts,鈥� Moreta said.

Proposed changes

More than 98% of Massachusetts residents have health insurance, the lowest rate of uninsurance in the country, according to the Massachusetts Health Insurance Survey.

Vicky Pulos, an attorney for the Mass Law Reform Institute who helps low-income people gain access to health care, said Republicans who tried and failed to repeal the Affordable Care Act during the first Trump administration have decided to take it apart incrementally despite its growing popularity.

鈥淚t really seems like this is just a less transparent way of effectively dismantling the accomplishments of the Affordable Care Act in both Medicaid and the marketplace,鈥� Pulos said.

The changes, she added, 鈥渨ill massively drive up the number of uninsured but without openly repealing the ACA.鈥�

Another provision included in both the House and Senate bills would require people applying for or renewing coverage to provide more documentation of their income, household size and immigration status to be eligible for premium tax credits when the state marketplace already has that information, which Morse Gasteier said would cause 鈥渇riction, red tape and delays.鈥�

The Trump administration has said the proposals will 鈥減ut a stop鈥� to immigrants 鈥渟tealing taxpayer-funded health care benefits meant for American citizens.鈥�

No states use federal money to provide health insurance to people who are in the U.S. illegally. Some, like Massachusetts, use state tax dollars to do so to provide basic primary care services for a small population of vulnerable residents, like children.

No undocumented immigrants receive insurance through the state marketplace.

Of the 400,000 enrolled in the state marketplace, around 60,000 are noncitizens who are in the U.S. legally and would lose access to federal premium tax credits if either chamber’s version of the bill becomes law. The number includes domestic violence and human trafficking victims, refugees, people granted asylum or humanitarian parole, temporary protected status and other work-authorized immigrants.

Without the credits, premiums will cost upwards of $500 or $600 鈥� an increase many people can’t afford, Morse Gasteier said. Around half are green-card holders with an annual income of $15,000 a year or less.

The remaining 40,000 people expected to lose coverage are U.S. citizens Morse Gasteier said could be stymied in applying or recertifying coverage by provisions like the increased documentation requirements.

Fears of trust l
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Morse Gasteier said Massachusetts’ marketplace worked 鈥渢irelessly鈥� to enroll vulnerable and hard-to-reach populations after the state program 鈥� formed under the leadership of then-Gov. Mitt Romney and known as 鈥淩omneycare” 鈥� was created.

She worries that if people hear help is no longer available, 鈥渆ntire populations will just sort of give up on health insurance.鈥�

In addition to affecting residents’ health, that could have an economic impact in the state.

Immigrants with legal status enrolled in the state marketplace tend to be younger than the rest of the population, Morse Gasteier said. Their presence brings premiums down for others because they tend to be healthier.

In Lawrence, advocates who help people obtain insurance coverage though the ACA marketplace say the burden would fall disproportionately on people with chronic health issues like diabetes and chronic heart disease.

The Greater Lawrence Community Action Council assists around 10,000 people a year with either signing up for or renewing health insurance.

鈥淚f you鈥檙e not healthy, let me tell you, you can鈥檛 work. If you can鈥檛 work, you can鈥檛 pay your bills. It鈥檚 just as simple as that,鈥� said GLCAC CEO Vilma Martinez-Dominguez.

Moreta said one man who called her from the emergency room recently said he discovered his health insurance had lapsed. Moreta said she could help him renew it, and urged him to wait at the hospital.

He told her not to do anything. He was leaving the hospital. She has no idea what became of him.