The U.S. House narrowly passed a Republican-backed health care plan last week, but the legislation now faces a long road in the Senate. The vote came about seven years after former President Barack Obama signed the Affordable Care Act into law.

Under the ACA, North Dakota and 30 other states expanded Medicaid to cover more low income people. During the most recent legislative session that ended in late April, North Dakota lawmakers extended the sunset date on its Medicaid expansion program for another two years, making it effective through July 31, 2019.

But the American Health Care Act would spell the end for Medicaid expansion, said Sen. Heidi Heitkamp, D-N.D., who derided the bill as a tax break for the richest Americans that would leave more people uninsured.

“The American Health Care Act is a horrible piece of legislation,” Heitkamp said in an interview Monday, May 8. She has pushed for fixing parts of the current law instead of repealing it.

Adults with a household income up to 138 percent of the federal poverty level qualify for Medicaid expansion. North Dakota’s enrollment has hovered around 20,000, said Maggie Anderson, the medical services division director for the state Department of Human Services.

Anderson said it’s premature to speculate how proposed changes to Medicaid expansion, as well as traditional Medicaid, might affect North Dakota.

Robin Rudowitz, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation, said the Republican bill would end the “enhanced matching dollars” for Medicaid expansion. The federal government covered 100 percent of the costs of the expansion initially, but that’s scheduled to drop to 90 percent by 2020.

“States can still elect to cover that population, but they wouldn’t be getting those enhanced match dollars,” she said. The federal match would switch to the rate for traditional Medicaid, which is about a 50-50 split between the federal and state government in North Dakota’s case, Rudowitz said.

As a result, Rudowitz said there’s an assumption that a number of states would drop out of the expansion.

Rep. Kevin Cramer, R-N.D., said the bill intends to “unwind” the Medicaid expansion program, but not to “pull the rug out from under people who are currently on it.” He noted that states would still receive enhanced matching funds for people who enroll in the expansion before 2020 and maintain continuous eligibility.

“It’s a population … that probably could do as well or better under our other scenarios,” Cramer said, pointing to tax credits and state flexibility the AHCA provides.

North Dakota lawmakers budgeted $633.3 million in state and federal funds for Medicaid expansion in the 2017-19 funding cycle, compared with $666.1 million for traditional Medicaid, including the Children’s Health Insurance Program, according to DHS.

It’s unclear how North Dakota state lawmakers would respond to federal health care changes. Mike Nowatzki, spokesman for Gov. Doug Burgum, said it was too early to speculate on what may come out of Congress.

Sen. Tim Mathern, D-Fargo, said Medicaid expansion has been especially important to rural health care providers who have a high number of Medicaid patients. But Jerry Jurena, president of the North Dakota Hospital Association, said it’s “pointless” to “get all worked up” about the House bill, given that he expects the Senate to make major changes over the coming months.

“We’re crafting our own bill,” said Sen. John Hoeven, R-N.D.

Hoeven expects changes to Medicaid expansion, but said he is focused on giving states more flexibility. He pointed to rising premiums under the ACA, otherwise known as Obamacare, as evidence congressional action is needed.

“Of course we have to have health care reform,” Hoeven said. “I think it’s going to take some time. I think it’s more important in getting it done right than it is in getting it done quickly.”

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Proposed Medicaid expansion rollback could impact 20K enrollees in ND