“It would be huge,” said Judy Swisher, head pharmacist and majority owner of Inspire Pharmacy in Grand Forks.

Those who work with Medicaid in the region say the program's 2014 expansion in North Dakota has helped many who were otherwise ineligible to take part. At the same time, the complicated nature of health care can make it difficult to gauge how the Republican Senate bill—if passed—will filter down to Grand Forks.

In its current form, the Senate GOP bill would result in steep cuts in Medicaid over time, shifting more financial responsibility to the states, as payments are capped and risk falling short of medical inflation.

A study by the Center for American Progress estimated the bill would result in 18,100 to 27,700 additional deaths by 2026, including 36 in North Dakota and 303 in Minnesota.

The nonpartisan Congressional Budget Office estimates 22 million Americans would lose health coverage under the Senate GOP bill, the Better Care Reform Act. Estimates of the number of North Dakotans who would lose coverage range from 31,100, according to the congressional Joint Economic Committee, to 70,000 from the Urban Institute.

The bill stalled earlier this week in the face of questions by Republicans, delaying a vote until after the July 4 congressional recess.

Sen. John Hoeven, R-N.D., has said the bill would have to be changed to win his support, and that he supports health coverage for low-income people through Medicaid or tax credits. Sen. Heidi Heitkamp, D-N.D., like other Senate Democrats, has been a vocal critic of the GOP health reform bills.

The most recent data available through the Grand Forks County Social Services office show about 4,500 families receiving Medicaid as of April 2017. Luellen Hart, the county's program administrator for economic assistance, didn't want to speculate too far down the line of what the health care bill would change. She said her office had tried—and was unable—to anticipate the effects of the Affordable Care Act and its eventual expansion of Medicaid in North Dakota.

Even if the GOP's bill is passed as it is, Hart doesn't believe its implementation and effect on Medicaid will be an easily defined picture. It took months to interpret the letter of the law for ACA, she said, and the federal law also known as Obamacare is still subject to differences in the way it's enacted from state to state.

"Our agency, you hear a lot of every side of story," Hart said. "Some were priced out of (coverage) and desperate, don't know what to do. Then you hear from ones that are so thankful that they have coverage when they didn't have it before, and pretty much everything in between."

Since April 2013, about 800 local families have been added to the program.

"The volume of applications was incredible," Hart said of the time after the expansion was passed.

Swisher describes some of the insurance plans that became available with the ACA as "horrible," but said Medicaid expansion has "been a real gift" to some of the pharmacy's customers who couldn't otherwise afford access to care.

While she doesn't like to talk about politics in connection to the pharmacy, Swisher said it "bothers her personally" to see the projected numbers of people who would lose access to Medicaid as suggested in the recent Congressional Budget Office report of the GOP bill. "I find it really troubling that that kind of stuff is hanging out there, it's discomforting," she said.

Provider impacts

Hospitals, nursing homes and physicians in North Dakota also are concerned about the impacts that would result from the loss of health coverage under Medicaid and reduced support for private insurance.

North Dakota recipients and health providers under Medicaid expansion would lose "hundreds of millions of dollars" under congressional GOP health reform plans, leading North Dakota hospitals told Hoeven in a letter. The losses would result from deep cuts to traditional Medicaid and reductions in federal tax credits and marketplace subsidies, the letter said.

At Altru Health System in Grand Forks, as many as 10 percent of those seeking care have Medicaid as their insurance, according to Teresa Moe, system supervisor of reimbursement and third party contracts. Jill Cormier, an Altru patient advocacy supervisor, described Medicaid as a kind of "crutch," in that many of the individuals she works with use it on a temporary basis to "get them on their feet."

Altru declined to take a stance on the bill itself, stating in a release that the company believes "everyone should have health care coverage" and that health systems "should be affordable for all, including the most vulnerable like those with illnesses, limited resources and individuals of any age."

North Dakota Medicaid would lose $1.2 billion through 2026, according to an estimate by the American Hospital Association. "Leaner tax credits and subsidies will extract from the state an additional $210 million," wrote the Health Policy Consortium executives, including Paul Richard, executive vice president of Sanford Health Fargo. "This massive reduction in resources will have severe fiscal and human impacts."

North Dakota hospitals would see an increase in uncompensated care totaling $27.9 million, according to the Joint Economic Committee. Charity care and bad debt by North Dakota hospitals totaled $274.8 million in 2014, the year Medicaid expansion began, and dropped 45 percent, to $150.7 million, in 2016, according to hospital industry figures.

Jerry Jurena, president of the North Dakota Hospital Association, said rural hospitals already are operating on the "financial edge," and some might close if the GOP health reform bills pass in their current form.

In 2014, North Dakota's 36 rural critical access hospitals, which have fewer than 25 beds, had a minus 5.1 percent operating margin.

Moe and Cormier didn't comment on the bill either but spoke favorably of Medicaid specifically. Moe says the program's expansion has helped the in-between segment of the population that was previously ineligible but also wasn't receiving insurance from an employer.

"It would be detrimental, I think, to lose the funding for Medicaid expansion," she said.

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