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House Republicans passed a huge tax and spending bill this week that now heads to the Senate. That legislation includes major changes to Medicaid, the federal health program for low-income people. The cuts lawmakers call for could have major repercussions across the country, especially in rural areas. John Daley with Colorado Public Radio went to the southern part of the state near Great Sand Dunes National Park to learn more about what may be at stake.
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JOHN DALEY, BYLINE: The San Luis Valley in south-central Colorado, clouds billow above the towering Sangre de Cristo Mountains as a stiff wind blows.
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DALEY: Uncertainty is in the air.
KONNIE MARTIN: I'm trying to be worried and optimistic.
DALEY: That's Konnie Martin, CEO of San Luis Valley Health in Alamosa. It's the flagship Hospital here, serving 50,000 people in six agricultural counties. Any changes to Medicaid could have tremendous ripple effects.
MARTIN: Because Medicaid is such a vital program to rural health care.
DALEY: Across the hall sits Shane Mortensen, the chief financial officer.
SHANE MORTENSEN: Yeah, the bean counter.
DALEY: He shows me a spreadsheet with a hospital's annual budget, $140 million. Medicaid payments account for nearly a third of that.
MORTENSEN: So major Medicaid cuts - it will be devastating to us. We will have to cut services.
DALEY: The San Luis Valley has three of the poorest counties in the United States. In one county, 57% of residents are enrolled in Medicaid. It's a lifeline, especially for people who don't have easy access to other coverage, like Julianna Mascarenas.
JULIANNA MASCARENAS: I looked, you know, into our insurance. And, oh, my goodness, it's just going to take half my check to pay insurance.
DALEY: She has six children and says Medicaid has covered her family for years.
MASCARENAS: Then how do I live? Do I insure my kids, or do I keep a roof over their head?
DALEY: Mascarenas works as an addiction counselor. Her ex-husband farms potatoes and cattle for employers that don't offer health insurance.
MASCARENAS: So those moments that I was a stay-at-home mom and he was working agriculture, what would we have even done? We would have had to pay out of pocket.
DALEY: Or go without. Across the state, Medicaid covers 20% of people - more than a million Coloradans. The hospital has a labor and delivery unit - the kind rural hospitals nationwide have struggled to keep open. But Dr. Carmelo Hernandez, the chief medical officer, worries that cuts could put it in jeopardy.
CARMELO HERNANDEZ: If we don't have obstetric services here, then where are they going to go? They're going to travel an hour and 20 minutes north to Salida to get health care. Or they can travel to Pueblo - another two-hour drive over a mountain pass - to get health care.
TIFFANY MARTINEZ: I'm a single mom of four, and I work with kids that have disabilities.
DALEY: Tiffany Martinez gave birth to her daughter Esme earlier this year. The pregnancy was high risk, requiring twice-a-week ultrasounds and stress tests at the hospital. She's enrolled in Medicaid. It's key, she says, for many moms in the valley.
MARTINEZ: Everything down here is low pay. It's not like we have money to just be able to pay for the doctor. It's not like we have money to travel often to go to the doctor, so it's definitely beneficial.
DALEY: Republicans in Congress say they want to save money, make government more efficient. Their proposed budget would require people on Medicaid to prove they're working, in school or are exempted. But it could force millions of people off Medicaid in the San Luis Valley. That would mean the hospital and clinics would be treating more uninsured patients with no prospect of reimbursement. Dr. Clint Sowards is a primary care physician. He says leaner hospital finances would make it harder to attract new doctors and nurses.
CLINT SOWARDS: Especially with needed health care services, certain specialties are no longer available, people will have to leave. They will have to leave the San Luis Valley.
DALEY: Downtown Alamosa has hotels, restaurants, shops and a coffee house called Roast Cafe. Barista Ethan Bowen makes a specialty drink called a drooling moose.
ETHAN BOWEN: It's a white chocolate mocha with a little bit of caramel in there.
DALEY: Sounds pretty good.
BOWEN: Oh, yeah.
DALEY: The coffee shop and brewpub next door does pretty good business, in part, because of hospital staff who work nearby.
BOWEN: Oh, a huge part of the local economy.
DALEY: I met Joe Martinez here. He's president of San Luis Valley Federal Bank.
JOE MARTINEZ: It's going to hit our community hard.
DALEY: He says the hospital's regional economic impact is more than $100 million a year. And if more people lose Medicaid coverage, that will hurt banking, small businesses and their workers.
MARTINEZ: Very worried as to how it affects the entire economy in the San Luis Valley.
DALEY: The hospital alone employs 750 people. Next door is Adams State University, the region's next biggest employer. Its president, David Tandberg, told me something most people don't realize.
DAVID TANDBERG: One of the biggest factors driving state higher education funding down is state spending on health care.
DALEY: This year, Colorado is facing a billion-dollar budget deficit, and universities like his find when state cuts are made, higher education competes with health care for precious funding.
TANDBERG: So anytime I hear about Medicaid cuts, it makes me nervous.
DALEY: And nervous is how many feel right now in the San Luis Valley.
For NPR News, I'm John Daley in Alamosa, Colorado.
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