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

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.

Gyle Peterson, a disabled 62-year-old Fargo man who is wheelchair-bound, was one of those protesting in front of Hoeven’s office. Peterson has muscular dystrophy and has been on a respirator for more than half of his life. He said he depends on Medicaid for survival.

“Our country was built on Christianity,” Peterson said in an open letter to Hoeven read by his caregiver. “But this certainly isn’t the Christian thing to do. God will frown and shake His mighty head if He sees that this bill gets passed.”

If passed, Peterson added, the Senate GOP bill would “kill thousands of us.” 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.

“This is fundamentally unfair,” said Amy Bauroth of Fargo, one of the protesters, who held a placard saying, “Trumpcare is a disaster.” “Where’s their moral argument for it?”

AARP petitions Hoeven

The nonpartisan Congressional Budget Office estimates 22 million Americans would lose their 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.

Monthly health insurance premiums would increase by $794 in 2018, according to the Joint Economic Committee’s calculations. Under the Senate GOP bill, those with incomes of up to 350 percent of the federal poverty level would be eligible for premium subsidies, compared to 400 percent under the Affordable Care Act.

The burden of higher costs for private health insurance and declining federal support for Medicaid would fall heavily upon the elderly, according to AARP North Dakota, whose members left petitions with Hoeven’s office Wednesday morning urging him to reject the Senate GOP bill.

“There’s an age tax in the bill that essentially allows health insurance to charge older individuals five times more for their health coverage” than young adults, said Josh Askvig, state director of AARP North Dakota, which has 87,000 members 50 and older. Under the Affordable Care Act, older people can be charged no more than three times the premiums paid by young adults.

A 64-year-old earning $26,500 would see a premium increase of $4,800 a year and would lose thousands of dollars of cost-sharing subsidies that help with costs such as co-pays, according to Congressional Budget Office figures. A 64-year-old earning $56,800 would see premiums skyrocket by $13,700, according to the CBO.

Hospitals push back

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.

Both the bill passed earlier by the U.S. House, which was supported by Rep. Kevin Cramer, R-N.D., and the Senate GOP bill would amount to a “massive cut impacting North Dakota patients and providers” and would “weaken the health care safety net for tens of thousands of North Dakotans,” members of the Health Policy Consortium wrote in the letter to Hoeven.

The Health Policy Consortium is comprised of administrators from many of North Dakota’s largest hospitals, including Sanford Medical Center Fargo, Sanford Medical Center Bismarck, Trinity Health in Minot and Altru Health System in Grand Forks.

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.

“I would say most of the hospitals are on the edge financially,” he said. In 2014, North Dakota’s 36 rural critical access hospitals, which have fewer than 25 beds, had a minus 5.1 percent operating margin.

“They’re already having trouble keeping up with medical inflation, Jurena said. “More and more hospitals are showing a negative bottom line.”

The Senate bill will be amended to try to win more support, but the outcome remains uncertain, he said. “Everyone’s trying to prepare themselves but we don’t know what to prepare for. It’s pretty unnerving.”

Shelly Peterson, president of the North Dakota Long Term Care Association said nursing home administrators are concerned about declining Medicaid support in both the House and Senate bills.

“We have a very old, old population in North Dakota nursing facilities, 51 percent on Medicaid,” she said. She’s glad the Senate has postponed a vote. “They need a more thoughtful approach,” she said.

Sen. Heidi Heitkamp, D-N.D., has been a vocal critic of the GOP health reform bills.\

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