Nearly 20,000 North Dakotans enrolled in the state’s Medicaid expansion stand to lose health insurance coverage if the Affordable Care Act is thrown out.

According to data from the North Dakota Department of Human Services, 19,542 residents have been enrolled in the Medicaid expansion as of December 2018. North Dakota was one of several states to expand Medicaid access under the ACA.

The Affordable Care Act, passed in 2010, remains on shaky ground after the Department of Justice this week supported a lower court’s earlier decision that would effectively invalidate the law. In December, U.S. District Judge Reed O’Connor said the removal of the individual mandate to obtain health insurance would effectively make the entire ACA invalid.

“The Department of Justice has determined that the district court’s judgment should be affirmed,” the department’s lawyers wrote in the filing.

Nationwide, nearly 20 million Americans could lose health insurance if the ACA is deemed unconstitutional, according to an analysis by the Urban Institute, a think tank in Washington, D.C.

Whether North Dakota or other states would opt to keep Medicaid expansions in place following a potential ACA repeal remains to be seen, but some observers say it’s unlikely. Under the ACA, states cover 10 percent of the cost of Medicaid expansion while the federal government picks up the remaining tab.

“Could states just sort of start their own program? I think the answer is likely no, just because you’re looking at a 90 percent difference in what they were paying before,” said Dana Harsell, associate professor of political science at the University of North Dakota. “This is assuming the absence of some sort of statutory or regulatory framework that would take (the ACA’s) place.”

And without insurance, many folks are more likely to use emergency rooms, which are often costly, said Mara Jiran, CEO of Valley Community Health Center.

“Once you have that health insurance coverage, then primary care becomes easier to access,” which means more preventative care and less reliance on ER trips, Jiran said.

Debbie Swanson, director of Grand Forks Department of Public Health, said a repeal could impact the wider community.

“There’s a lot more at stake than just individual coverage,” Swanson said. “Making sure people have basic coverage is really important to protecting everybody in the community.”

In Minnesota, about 1.2 million residents could be “negatively impacted” by a repeal of ACA, the state’s department of human services said in a statement.

“Hardest hit will be those currently covered by Minnesota’s Medicaid and MinnesotaCare programs, which includes children, seniors and people with disabilities,” the department said. “Also impacted, but not included in that number are the people who are receiving tax credits in the individual market, or Minnesotans with pre-existing conditions benefiting from protections under ACA.”

In addition, Minnesota could lose about $2 billion each year in federal funding to provide health care, according to the department.

“Accessible, affordable, quality health care has long been a priority for Minnesota,” said Tony Lourey, Minnesota’s commissioner of human services, in a statement.

If the ACA is ultimately ruled unconstitutional, President Trump would like to have a replacement plan “ready to go,” U.S. Sen. Kevin Cramer, R-N.D., said in a statement.

“North Dakotans have never fallen for the lie that anyone would be ‘kicked off’ their health care plan; that was President Obama’s broken promise when he pushed this through a Democratic-controlled Congress,” Cramer said. “If the Appellate Court strikes down the law, it would make sense to have a plan that brings down premiums, provides choice and protects people with preexisting conditions.”