While discussion about repealing or revamping the Affordable Care Act, or Obamacare, swirls around Washington, D.C., a local health care leader says whatever happens in D.C. will impact Stevens County.

ACA provides health care for 21 million people in the U.S. who were previously uninsured. For Stevens Community Medical Center that means fewer people using the emergency room for primary care needs, said SCMC Chief Executive Officer Jason Breuer.

The end result is less unpaid debt for services provided.

SCMC is a not-for-profit hospital and it cannot refuse emergency room care to any patient in need. If that patient does not have insurance it can often mean some, or all, of the emergency room care provided is not paid for.

Specifically, ACA, reduced Minnesota's 9 percent rate of uninsured to 4 percent, said Wendy Burt of the Minnesota Hospital Association. "Because 96 percent of all Minnesotans have health insurance, the charity care that was historically provided has been reduced," Burt said.

ACA expanded Medicaid which is a health care insurance program funded by the federal government. Hospitals receive reimbursement from services they provide to Medicaid patients. If ACA is repealed or changed and those reimbursements are cut or reduced significantly, that would harm hospitals such as SCMC, Burt and Breuer said.

ACA also provided an option for rural hospitals to use for drug purchases and that has been a cost savings for SCMC, Breuer said.

ACA also helps with the need to provide better managed care for patients which in the end, saves money for the government, healthcare providers and the patient, Breuer said.

If more people have health insurance they will use primary care providers for services to manage their diabetes, high blood pressure and other conditions, Breuer said. They can focus on wellness in diet, exercise and other choices, he said.

Without insurance, patients are vulnerable to neglecting their care until their health deteriorates and forces a trip to the E.R. or expensive procedures, Breuer said.

And one change he'd like in ACA or its replacement is reimbursements that don't reward patient visits or traditional services provided as much as rewarding healthcare providers who reduce the need for patient visits because of well-managed patient care, Breuer said.

Minnesota is not the only state watching the D.C. discussion about ACA.

A Jan. 18 story in the Denver Post said rural Colorado hospitals were at risk if ACA was repealed without an adequate replacement. A Jan. 11 story in MedCity News said full repeal of the ACA without a comparable replacement could be the death knell for rural hospitals because of potential loss of Medicaid reimbursements and other ACA benefits.

"Federal funding should not be reduced but it should be flexible to allow innovations at the local level...," Burt said.

Minnesota has a history of being innovative in providing healthcare to low income patients and the working poor as well as innovations in healthcare delivery to all patients, Burt said.

Burt said MNSure, a Minnesota program created under ACA, did have it's hitches when it was first introduced but ultimately, 60 percent of those insured under the program received federal subsidies for the premiums, Burt said.

About 100,000 more Minnesotans were insured under the MNSure program, Burt said.

"There are two sides to the story," Breuer said. "Some say ACA is very expensive to maintain but what about 21 million people who were not covered under insurance (before ACA)," Breuer said.

Breuer said the ACA insurance exchange had some challenges as more people of an older age chose plans with a higher level of care and fewer younger people chose less expensive plans. That was one reason why some insurance premiums rose after ACA was implemented, Breuer said.

Any change in ACA, even a repeal, must include a replacement, Burt and Breuer said.

"The American Hospital Association has made a key point and said any replacement needs to come simultaneously with a (any repeal)," Burt said. "We (MHA) would agree with that."