Congress is in recess, but when it returns to Washington, D.C. on April 28, Republicans in the House and Senate will be working overtime to finish the details of the sprawling domestic policy bill that is central to President Donald Trump’s agenda.

One of the most closely watched portions of the bill centers on the future of Medicaid, which provides coverage of health and long-term care to 83 million low-income Americans and people with disabilities. It is jointly financed by states and the federal government. House Republicans are driving the charge to reduce the federal government’s share by hundreds of billions of dollars over the next decade. They say it can be done without cutting services, but many analysts disagree.

Local healthcare providers in Ulster County are concerned enough to have spent the past several months lobbying state and federal officials. They are apprehensive about the potential impact of Medicaid cuts on people’s health and what it may mean for their organizations’ finances.

“I think we’re all sort of quaking in our boots, wondering what could happen, and I think we know it won’t be good,” said Steven Kelley, president and CEO of Ellenville Regional Hospital, a 25-bed critical access hospital.

In March, Kelley met with Congressman Josh Riley to make the case to preserve federal funding of Medicaid. Kelley and others from the Healthcare Association of New York State, whose members are hospitals, nursing homes, and other healthcare organizations, have also met with leaders in the New York State legislature and the state’s budget director.

Dr. Eric Gayle, a family physician and president and CEO of the nonprofit Institute for Family Health, which operates Ellenville Family Health Center and other health centers in the Mid-Hudson Valley, Brooklyn, Manhattan, and the Bronx, has also met with elected officials. He and other heads of community health centers are continuing “to press our legislators in the state and in the capital to minimize any impact, whether on the state or federal level, of cuts to our Medicaid program,” said Gayle.

Ulster County has 48,838 people enrolled in Medicaid as of February, 27% of the county’s population. That’s an increase of nearly 13% from the number of enrollees a decade ago, when the Affordable Care Act expanded Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level. New York is one of 41 states that adopted Medicaid expansion.

The split of healthcare costs of traditional Medicaid enrollees varies from state to state. In New York, the federal government and the state split it evenly. In all states, the federal government pays 90% of the costs for people enrolled in Medicaid under the Affordable Care Act expansion, with states paying the balance.

There are many ways that Congress could reduce federal funding of Medicaid.

One proposal is to withhold funding for adults enrolled through Medicaid expansion who do not report working for at least 80 hours per month or meet exception requirements. The Urban Institute, a nonprofit research organization, said that 9 in 10 adults in Medicaid expansion already work or would be exempt. Nevertheless, “low awareness and understanding of the policy and difficulty using state reporting systems” has institute researchers predicting that many would still lose coverage, including nearly 900,000 New Yorkers, according to an April report.

Other federal policies to cut Medicaid might include changing eligibility rules, capping total Medicaid funding – it is not capped currently – or reducing Medicaid matching rates, for instance lowering the 90% share that the federal government pays for Medicaid expansion enrollees or the 50% it covers for New York State traditional Medicaid enrollees.

All would shift costs to states, which would face the difficult choice of preserving Medicaid by raising taxes or finding savings elsewhere or cutting back Medicaid services and enrollees. So far, New York State legislators “can’t give us any answers about what they’re going to do,” said Gayle.

The New York State legislature and Governor Kathy Hochul are in the midst of hammering out the state budget for fiscal year 2025. They are proceeding as if there will be no changes to Medicaid from the U.S. Capital, although state Budget Director Blake Washington says they’re prepared to “modify” the budget if needed.

Both Gayle and Kelley are concerned that if the state has to cut services and reduce the number of Medicaid enrollees, people’s health will suffer. Currently, 45% of the 5,000 annual patients seen at Ellenville Family Health Center are enrolled in Medicaid. More than a third of Ellenville Regional Hospital’s patients are enrolled.

Gayle remembers what happened during the height of the Covid pandemic, when people still had insurance but were afraid to make in-person visits to the clinic. “They didn’t come into health centers, and their health deteriorated,” including control of their blood pressure and diabetes, Gayle said. He expects the same kind of regression in health if people lose Medicaid and stop showing up at the clinic for primary care.

“We’ll end up with more emergency care [at the hospital] that could have been avoided through visits to local doctors,” said Kelley. He also anticipates the state could instruct the private entities that administer its Medicaid program to deny more healthcare services.

Kelley expects any Medicaid cuts to hit his bottom line. That’s because the hospital must treat anyone who shows up, no matter their insurance status, and uninsured patients often cannot pay out of pocket. Ellenville Regional Hospital has an operating margin of 4 percent, better than almost all other critical access hospitals in the state, many of which are losing money, and enough to insulate the hospital in the short-term, said Kelley. Still, that is only about one percentage point above the current inflation rate. “In the long-term, it’s very hard to say how we’d do. We’ve been through two bankruptcies here already, in 1999 and 2003,” he said.

Ellenville Family Health Center also does not turn away patients without insurance, and Gayle said the institute would make sure patients knew of the policy so that they continue their care if they lost Medicaid coverage. When asked where the money would come from to treat a greater number of uninsured patients, “This is not something that we’re ready to examine,” said Gayle.