A medical assistance program that serves nearly 20,000 North Dakotans faces potential changes under a Republican health plan introduced in the U.S. House in February.

Maggie Anderson, medical services director overseeing the Medicaid division in the North Dakota Department of Human Services, said the plan does not eliminate Medicaid Expansion eligibility, but it does considerably reduce the federal money in the partnership with the states.

The existing Affordable Care Act provided 100 percent federal funding for the Expansion population from 2014 through 2016. Starting last January, the federal match began to decrease and will taper to 90 percent by 2020.

As introduced, the Republican health care bill would continue covering individuals who are enrolled in Medicaid Expansion at the end of 2019 at the 90 percent federal match. Starting in 2020, any new enrollees would be covered but at the 50 percent match that exists for traditional Medicaid. Should grandfathered enrollees discontinue for longer than 30 days, they would be considered new enrollees if they sign up again.

Expanded Medicaid brought assistance to more people because it opened up eligibility to anyone up to 138 percent of poverty without requiring other qualifying conditions, such as pregnancy, age or disability.

The Obama Administration’s Affordable Care Act also provided presumptive eligibility, which meant if an uninsured patient who was eligible for Expanded Medicaid presented at a hospital, that person could be considered covered by the program. That provision goes away in the new health care proposal, Anderson said.

The Department of Human Services had estimated 20,500 North Dakotans would be eligible for Expanded Medicaid. Initial enrollment was well below that figure, but numbers rose and eventually leveled off near the estimate, Anderson said. As of last September, there were 19,358 individuals enrolled.

Statistics show 58 percent of enrollees are rural; 54 percent are female; 48 percent are ages 19 to 35; 18 percent are ages 35 to 44; and 34 percent are ages 45 to 64. Medicaid serves individuals to age 65.

The Department of Human Services funding bill before the Legislature would continue North Dakota’s participation in Medicaid Expansion through the next biennium, which ends July 31, 2019. Any decision to continue past that time would fall to the 2019 Legislature. State participation has been optional. North Dakota opted to participate beginning in January 2014.

The state funding bill also makes a change, effective in 2018, that requires recipients and applicants aged 19 to 21 to receive coverage through traditional Medicaid rather than Medicaid Expansion. The bill continues to work its way through the Legislature.

“Medicaid Expansion has been very positive in terms of reducing our uncompensated care in the state,” said Tim Blasl, vice president of the North Dakota Hospital Association

Uncompensated care, including bad debt and charity care, totaled about $274 million in 2014. Last year, uncompensated care totaled $150 million for the 48 hospital members of the association, said Blasl, who attributed much of the change to Medicaid Expansion.

That increased compensation means more money for hospitals to invest in equipment, staff and services to patients, he said. Health-care premiums of the insured might be less affected, but there is a connection between a hospital struggling because of uncompensated care and the reimbursements they need from insurers to remain viable, he said.

Randy Schwan, Trinity spokesman, said Medicaid Expansion would be one of the reasons why Trinity’s charity care expenses have gone down since 2014. He said Trinity still spends millions on charity care, and it has seen a rise in bad debt, stemming from patients ineligible for charity care who don’t pay. However, the additional reimbursement through Medicaid Expansion has been beneficial, he said.

“Our costs certainly go up trying to identify and get people enrolled in Medicaid Expansion and other programs, but at the end of the day, we felt the return on that was still positive,” Schwan said.

Congressman Kevin Cramer, R-ND, said Congress needs to get a handle on the rising cost of medical programs. Efforts to preserve Medicaid Expansion could diminish the opportunity to shore up Medicaid, which serves the most vulnerable population, he said. Having a transition period that allows existing recipients of Medicaid Expansion to remain on the program also aids families with children with disabilities who have been concerned losing assistance they need for the long-term, Cramer said.

He added he supports increasing Medicaid reimbursement for elderly and disabled recipients and providing states with flexible grants that can be used to support the Medicaid population, support medical institutions such as rural hospitals or address other health priorities of individual states.

Sen. Heidi Heitkamp, D-ND, said she is concerned about the proposed change to Medicaid Expansion because 17 to 20 percent of North Dakota’s drug treatment payments come from the program. Investing in treatment saves money in emergency services and other care related to drug abuse, she said.

Without the assurance of Medicaid Expansion, there also could be incentive for some people to work less to bring their incomes down to qualify for traditional Medicaid, Heitkamp said. Other people might go uninsured, she added.

Sen. John Hoeven, R-ND, said he is still investigating how to best address the Medicaid Expansion program.

“While the bill is still making its way through the legislative process in the House, I will continue reviewing the legislation and speaking with stakeholders in North Dakota to learn more about the potential impact on our state. I am working with my colleagues in the Senate to ensure that those who gained coverage under Medicaid Expansion will continue to have access to care moving forward,” he said.