In southern Colorado's San Luis Valley, clouds billow above the towering mountains of the Sangre de Cristo range. A chorus of blackbirds whistle, as they flit among the reeds of a wildlife refuge. Big circular fields of crops, interspersed with native shrubs, give it a feel of bucolic quiet.
Despite the stark beauty in one of the state's most productive agricultural regions, there's a sense of unease among the community's leaders as Congress debates a budget bill that could radically reshape Medicaid, the government health program for low-income people.
"I'm trying to be worried — and optimistic," said Konnie Martin, CEO of San Luis Valley Health in Alamosa. It's the flagship health care facility for 50,000 people in six agricultural counties — Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache.
The numbers out of the bill about deep Medicaid cuts were "incredibly frightening," Martin said, "because Medicaid is such a vital program to rural health care."
Martin's hospital is not alone. "I think in Colorado right now, nearly 70 percent of rural hospitals are operating in a negative margin," in the red, Martin said.
Across the hall from her office is Shane Mortensen, the chief financial officer. "The bean counter," he said with a slight grin.
The hospital's annual budget is $140 million, and Medicaid revenues make up nearly a third of that, according to Mortensen.
The operating margin is razor thin, so federal cuts to Medicaid could force difficult cuts. "It will be devastating to us," Mortensen said.
Lifeline for health care
The region is one of the state's poorest. Two in five of Alamosa County's residents are enrolled in Health First Colorado, the state's Medicaid program.
It's a lifeline, especially for people who wouldn't otherwise have easy access to health care. That includes low-income seniors who need supplemental coverage over and above Medicare, and people of all ages with disabilities. More than 2,500 working age adults in the county with incomes lower than $20,820 a year also qualify, and would be among those most likely to lose coverage under current proposals.
Envisioning a future with deep cutbacks leaves many patients on edge.
"I looked into our insurance and, oh my goodness, it's just going to take half my check to pay insurance," said Julianna Mascarenas, a mother of six. She says Medicaid has helped her cover her family for years. "Then how do I live? Do I insure my kids or do I keep a roof over their head?"
Mascarenas works as a counselor treating people with substance use disorder. Her ex-husband farms, potatoes and cattle, for employers that don't offer health insurance.
"So those moments that I was a stay-at-home mom and he's working agriculture, what would've we even done? I don't even know," she said, when asked what would have happened if Medicaid wasn't there. "Now that I think back, what would have we done? We would've had to pay out of pocket."
Or go without. Across the state, Medicaid covers one in five Coloradans, more than a million people.
That includes children in foster care.
"We've had 13 kids in and out of our home, six of which have been born here at this hospital with drugs in their system," said Chance Padilla, a foster parent. "Medicaid has played a huge part in just being able to give them the normal life that they deserve."
He and his husband, Chris, who are both clinic managers, get reimbursed by Medicaid for the costs of providing for the kids that have lived with them. "These kids require a lot of medical intervention," said Chance Padilla.
The program also covers mental health services for foster children. "At one point, we had a preteen that needed to be seen three times a week by a mental health professional," Chris Padilla said. "There's no way that we could have done that without Medicaid."
What happens to cancer and maternity care?
San Luis Valley Health's lobby is modern, built of red brick and glass. Down a hallway is the cancer center where patients come for chemotherapy transfusions. Nurse Amy Oaks demonstrates how they ring a ceremonial bell, to celebrate each time a patient finishes a course of treatment.
"It's just a happy time," said Oaks. "It's exciting. It gives you the chills, makes you cry."
But hospital staff and administrators wonder whether federal cuts would make it hard for the hospital to keep the cancer center running.
"It could be pretty dramatically affected," said Dr. Carmelo Hernandez, the chief medical officer.
Hernandez's specialty is obstetrics and gynecology. The hospital has its own labor and delivery unit, the type of service that other rural hospitals across the U.S. have struggled to keep open.
"If we don't have obstetric services here, then where are they going to go?" Hernandez asked. "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, 34, works with kids who have disabilities. She was recently forced to think about that possibility after giving birth to her fourth child, Esme, three weeks ago.
Her pregnancy was high risk, requiring twice-a-week ultrasounds and stress tests at the hospital. She's enrolled in Medicaid and said it's critical for many moms in the valley.
"Everything down here is low pay," said Martinez. "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."
About 85 percent of the hospital's labor and delivery patients are covered by Medicaid. As the program has expanded over the years, many of the patients who got added were married women from working families.
"It impacted the whole family because of course that's a little nucleus then that grows with the care of the family and the well-being of the family," said Christine Hettinger-Hunt, the hospital's chief operating officer.
Hospital heals, and also employs
With 750 workers, the hospital is the valley's largest employer. One of those employees is Dr. Clint Sowards, a primary care physician. He grew up in the region, went away for school and came back to a good-paying job.
Sowards is focused on the fact that fewer Medicaid funds will make it harder to attract the next generation of doctors, nurses and other health providers.
Certain medical specialties might no longer be available, Sowards explained. "People will have to leave. They will have to leave the San Luis Valley."
Dr. Kristina Steinberg is a family medicine physician with Valley Wide Health Systems, a network of small clinics serving thousands. She said Medicaid covers most nursing home residents in the area. "If seniors lost access to Medicaid for long-term care, we would lose some nursing homes," she said. "They would consolidate."
The program also pays for vaccines for children. In two nearby communities, Colorado recently recorded its first cases of measles this year, which is highly contagious.
"If you are on Medicaid, you don't have any insurance, you pretty much qualify for free vaccines for children," Steinberg said. "And I can see our vaccines dropping off dramatically if people have to pay for vaccines, because some of them are very expensive."
Medicaid sustains a local level of health care that is then available to the wider population, including patients on Medicare and commercial insurance, according to administrators and clinicians.
"We really utilize Medicaid as sort of the backbone of our infrastructure," said Audrey Reich Loy, a licensed social worker and the hospital's director of programs.
"It doesn't just support those that are recipients of Medicaid, but as a result of what it brings to our community, it allows us to ensure that we have sort of a safety net of services that we can then expand upon and provide for the entire community."
Seeking more efficiency
Republicans in Congress say they want to save money and make the government more efficient. Their budget would cut taxes by trillions of dollars — and possibly cut social safety net programs like Medicaid.
Many in this region voted for President Trump — in Alamosa County, he topped 54 percent. Hernandez admits Medicaid cuts could give people here second thoughts.
"He's potentially affecting his voter base pretty dramatically," said Hernandez, noting politics is a sensitive topic that he mostly doesn't discuss with patients. "I can't imagine that hasn't crossed some people's minds."
Sowards, the family medicine physician, says he's baffled by the idea of potentially slashing Medicaid spending. He understands that some people believe the Medicaid system is ailing and costly. But he has grave doubts about the proposed cure.
"Just because we fall and break our wrists and our wrist is broken, doesn't mean that we need to cut off our arm, okay?," he said. "Losing Medicaid would have drastic repercussions that we can't foresee."
Local economy depends on health care
Deep Medicaid cuts could pack a punch for the wider regional economy as well.
The small city of Alamosa is the hub of the San Luis Valley. It has a main street in the midst of revitalization. It has hotels, restaurants, shops and a coffee shop called Roast Cafe.
On a recent Wednesday, barista Ethan Bowen prepped a specialty drink called a Drooling Moose. "It's a white chocolate mocha with a little bit of caramel in there," he said.
The coffee shop and its adjacent brew pub do pretty good business here — in part because of foot traffic from nearby San Luis Valley Health, which is a "huge part of the local economy," Bowen said.
Joe Martinez is president of San Luis Valley Federal Bank, the valley's oldest financial institution. It's on the next block.
He said the valley is home to three of the poorest counties in the nation. A lot of its people are enrolled in Medicaid "and the individuals that partake in the program don't necessarily have the financial means to travel outside of the San Luis Valley for health care."
Cuts would hit hard
The hospital's regional economic impact is more than $100 million a year, with Medicaid accounting for a major part of that, Martinez said.
Any Medicaid cuts would hit the hospitals hard, but also affect small businesses and their employees. The region is already feeling economic stress from other changes, like recent cuts the Trump administration made to the federal workforce.
The San Luis Valley is home to the Monte Vista National Wildlife Refuge, Great San Dunes National Park and other federally-managed lands.
Martinez said recently laid off federal workers are already coming to banks, saying, "'Can I find a way to get my next two months mortgage payments forgiven? Or can we do an extension? Or I lost my job, what can we do to make sure that I don't lose my vehicle?'"
Ty Coleman, Alamosa's mayor, traveled to Washington, D.C., in April to talk to the state's Congressional delegation. He said his message about Medicaid cuts was straightforward: "It can have a devastating economic impact." Coleman put together a long list of possible troubles: more chronic disease and mortality, longer wait times for care, medical debt and financial strain on families.
"It's not just our rural community, but the communities, rural communities, across Colorado as well and the United States," Coleman said. "And I don't think people are getting it."
Cuts would create ripple effect
Medicaid cuts indirectly can impact other economic sectors, like education.
"One of the biggest factors driving state higher education funding down is state spending on health care," said David Tandberg, president of Adams State University in Alamosa. The college has roughly 3000 students and is next door to the hospital. It's the region's second-largest employer.
If federal cuts are made to Medicaid, Tandberg said, the state of Colorado will then be forced to pay more to maintain health care services. This year, Colorado is facing a billion-dollar budget deficit. Public universities like his will find they're competing with medical institutions for precious state funding. "So anytime I hear about Medicaid cuts, it makes me nervous," he said.
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