GRAND FORKS—Devin Schaan, a single mother living in Grand Forks, never knew that her diabetes would shape so much of her budget. And she never expected that, as she balanced her needs against the health care bureaucracy, it could drive her so close to the edge of what she can afford.
Schaan's troubles peaked earlier this year, when her insurance company's rates went up and she was left waiting to receive one of the Affordable Care Act's selection of insurance plans until January—the soonest the law would let her receive new insurance.
That's because there's only a narrow, year-end period to enroll in the ACA, designed to encourage people to sign up before they're sick. Without it, the logic goes, people would just wait to buy insurance until they need it. That's untenable for insurance companies.
But that was cold comfort for Schaan, who needed to make ends meet now—not in January.
"I'm like, OK, I don't have $600. I just paid day care, I just paid rent. I don't have $600 to give you. I have about $200, which is what I was expecting it to be," she said, recalling an autumn conversation with her insurance company, whose plan she hadn't purchased under the Affordable Care Act. "I ended up digging into my savings for a month of insulin."
It was one of the most frustrating moments Schaan has faced as she grapples with the world of health insurance—highly complex and, for many, still expensive. She'll be moving to a less expensive plan soon, Schaan said, but she said the she's frustrated with the apparently endless politicking with how she pays for her treatments.
"You see everything on news ... and then Trump has this whole idea of a better system, and his system isn't any better than the first system they came up with," she said. "So it's very frustrating and you end up shutting it off—not paying attention to it. I mean I've had anxiety attacks over being able to afford it."
But for people who buy their own health insurance, life could get more expensive. A Republican tax overhaul bill includes a revision that repeals the "individual mandate" in the Affordable Care Act—which could mean many people losing their insurance or paying more.
The mandate is the requirement that all people have health insurance or pay a tax penalty. It's in place to ensure enough healthy people buy insurance. Without the mandate, people are more likely to only buy health insurance when they're sick—which means health insurance companies see revenues drop, and either hike their rates or withdraw from the market as a result.
In North Dakota, there are three groups offering plans on the open marketplace: Blue Cross Blue Shield, Sanford Health and Medica—though Sanford is not as widely available as Blue Cross Blue Shield, and Medica will pull out of the market in 2018. In Minnesota, the state-run exchange has four insurance companies—Medica, Blue Plus, UCare and HealthPartners.
Jeremy Drucker, the senior director of public affairs for Minnesota's exchange, said the loss of a mandate could mean big changes.
"It's all under this umbrella of further destabilization of the individual market—increased premiums, narrowing networks, fewer insurance companies that want to get involved," he said. "At the end of the day, it's the people on the ground who really feel the effects of that."
And as the tax overhaul bill heads towards final passage, there's worry that the repeal of the mandate will become law, worsening rates and availability.
"There will be some people who choose not to get the insurance, and then if they get sick, those are the individuals who could wind up going bankrupt as a result," said Donald Warne, chairman of North Dakota State University's Department of Public Health. "But then there will be people who would otherwise stick with their insurance who would not be able to keep it (as costs increase)."
The debate over health care's future suffers from the partisanship that has dogged the Affordable Care Act since its passage in 2010, something Warne and other experts lament.
"If we could get over the politics of one side versus the other it would really be refreshing, because, you know, I think there are bipartisan approaches" to improving health care, said Pete Antonson, CEO of Northwood Deaconess Health Center. "Unfortunately, I don't think Washington chooses to be bipartisan any longer. So I think there are improvements that need to be made."
Plans are in place to soften the blow to insurance markets, but it's still not clear where they'll go. Sen. Susan Collins, R-Maine, said shortly after the passage of the Senate tax bill that "I got a commitment" on the passage of two bills that would help lower health care premiums and stabilize insurance markets.
Sen. Heidi Heitkamp, D-N.D., has said she supports a range of bills that stabilize health care markets and improve Obamacare's structure. She said she's worried about what could happen to the millions of people who could lose insurance if the mandate is repealed, which is estimated at 13 million nationwide.
Sen. John Hoeven, R-N.D., voted for the tax bill. He sees an opportunity for a compromise in the aftermath of the individual mandate's repeal, potentially starting with the same legislation that Heitkamp and Collins are interested in—in a process he said would result in more choice and competition for consumers.
"It comes down to, should people have a choice, or should the government mandate what they do?" he said.
That's not to mention CHIP—that's Children's Health Insurance Program—which caters to children in a range of low-income families making too much to receive Medicaid. It's well-liked program for both parties, but its future has been put at risk as its funding runs low and as Congress cannot seem to agree on a path ahead.
And as many health experts—even boosters of Obamacare—have said, American health care law has been imperfect for years. Brad Gibbens, the deputy director of the University of North Dakota's Center for Rural Health, said health care is regulated in a "silo" system, meaning many of the regulations that affect hospitals differ from those that affect similar providers, such as nursing homes. That can be an unnecessary headache for health care systems that have multiple types of facilities.
"There's a pretty heavy—even in a rural hospital—staffing burden, just to stay up on regulations and make sure things are being coded the right way," Gibbens said. "Then you have to hire an accounting firm to make sure your charges are right."
'Other nations do it'
There are big ideas for how to change the health care system that go far beyond the next several months, or even the next several years. Antonson wondered about a kind of "subscription" plan that keeps patients continually receiving checkups to keep them from getting ill.
"I mean that's really dreaming big, but we need to try to figure out how to stay healthier as a society," he said. "We need to figure out how ... two thirds of our country can't be overweight and obese and have good health outcomes. We really have to figure out how can we work in our community and be paid to help keep people healthy and not get them healthy after they're sick."
And then there's universal health care, which Warne said is actually a smart business move, freeing up massive amounts of money companies now pay into benefits and giving entrepreneurs—who may be giving up employer plans to start their own business—one less thing to worry about.
But rejecting universal health care is something all of North Dakota's delegates agree on. Hoeven said "government-run" health care isn't "what Americans want." Heitkamp said it's "unrealistic," and that the current system ought to be improved. Rep. Kevin Cramer, R-N.D., said such a plan is at odds with core American values.
The office of Rep. Collin Peterson, D-Minn., did not return a request for comment. Sen. Amy Klobuchar, D-Minn, responded to a set of questions on health policy and universal health care with concerns for the effects of the GOP's tax bill on insurance markets and the need for a "bipartisan" approach.
"Our focus should be on moving forward with bipartisan legislation that will help Minnesota families by ensuring everyone has affordable, high-quality health care and reducing the high cost of prescription drugs."
Whatever course future leaders set, it's bipartisanship that Warne hopes will rule the day.
"I think there's so much of the humanity and concern that we should have for one another that's taken out of the debate and out of the argument," he said. "Other nations do it. Why can't we provide health services that are available? We just need to find ways to pay for it that are reasonable."