Category: Rehab News

Conservative groups are working to undermine support for Montana’s Medicaid expansion in hopes the state will abandon the program. The rollback would be the first in the decade since the Affordable Care Act began allowing states to cover more people with low incomes.

Montana’s expansion, which insures roughly 78,800 people, is set to expire next year unless the legislature and governor opt to renew it. Opponents see a rare opportunity to eliminate Medicaid expansion in one of the 40 states that have approved it.

The Foundation for Government Accountability and Paragon Health Institute, think tanks funded by conservative groups, told Montana lawmakers in September that the program’s enrollment and costs are bloated and that the overloaded system harms access to care for the most vulnerable.

Manatt, a consulting firm that has studied Montana’s Medicaid program for years, then presented legislators with the opposite take, stating that more people have access to critical treatment because of Medicaid expansion. Those who support the program say the conservative groups’ arguments are flawed.

State Rep. Bob Keenan, a Republican who chairs the Health and Human Services Interim Budget Committee, which heard the dueling arguments, said the decision to kill or continue Medicaid expansion “comes down to who believes what.”

The expansion program extends Medicaid coverage to adults with incomes up to 138% of the federal poverty level, or nearly $21,000 a year for a single person. Before, the program was largely reserved for children, people with disabilities, and pregnant women. The federal government covers 90% of the expansion cost while states pick up the rest.

National Medicaid researchers have said Montana is the only state considering shelving its expansion in 2025. Others could follow.

New Hampshire legislators in 2023 extended the state’s expansion for seven years and this year blocked legislation to make it permanent. Utah has provisions to scale back or end its Medicaid expansion program if federal contributions drop.

FGA and Paragon have long argued against Medicaid expansion. Tax records show their funders include some large organizations pushing conservative agendas. That includes the 85 Fund, which is backed by Leonard Leo, a conservative activist best known for his efforts to fill the courts with conservative judges.

The president of Paragon Health Institute is Brian Blase, who served as a special assistant to former President Donald Trump and is a visiting fellow at FGA, which quotes him as praising the organization for its “conservative policy wins” across states. He was also announced in 2019 as a visiting fellow at the Heritage Foundation, which was behind the Project 2025 presidential blueprint, which proposes restricting Medicaid eligibility and benefits.

Paragon spokesperson Anthony Wojtkowiak said its work isn’t directed by any political party or donor. He said Paragon is a nonpartisan nonprofit and responds to policymakers interested in learning more about its analyses.

“In the instance of Montana, Paragon does not have a role in the debate around Medicaid expansion, other than the testimony,” he said.

FGA declined an interview request. As early as last year, the organization began calling on Montana lawmakers to reject reauthorizing the program. It also released a video this year of Montana Republican Rep. Jane Gillette saying the state should allow its expansion to expire.

Gillette requested the FGA and Paragon presentations to state lawmakers, according to Keenan. He said Democratic lawmakers responded by requesting the Manatt presentation.

Manatt’s research was contracted by the Montana Healthcare Foundation, whose mission is to improve the health of Montanans. Its latest report also received support from the state’s hospital association.

The Montana Healthcare Foundation is a funder of KFF Health News, an independent national newsroom that is part of the health information nonprofit KFF.

Bryce Ward, a Montana health economist who studies Medicaid expansion, said some of the antiexpansion arguments don’t add up.

For example, Hayden Dublois, FGA’s data and analytics director, told Montana lawmakers that in 2022 72% of able-bodied adults on Montana’s Medicaid program weren’t working. If that data refers to adults without disabilities, that would come to 97,000 jobless Medicaid enrollees, Ward said. He said that’s just shy of the state’s total population who reported no income at the time, most of whom didn’t qualify for Medicaid.

“It’s simply not plausible,” Ward said.

A Manatt report, citing federal survey data, showed 66% of Montana adults on Medicaid have jobs and an additional 11% attend school.

FGA didn’t respond to a request for its data, which Dublois said in the committee hearing came through a state records request.

Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, also declined to comment. As of late October, a KFF Health News records request for the data the state provided FGA was pending.

In his presentation before Montana lawmakers, Blase said the most vulnerable people on Medicaid are worse off due to expansion as resources pool toward new enrollees.

“Some people got more medical care; some people got less medical care,” Blase said.

Reports released by the state show its standard monthly reimbursement per Medicaid enrollee remained relatively flat for seniors and adults who are blind or have disabilities.

Drew Gonshorowski, a researcher with Paragon, cited data from a federal Medicaid commission that shows that, overall, states spend more on adults who qualified through the expansion programs than they do on others on Medicaid. That data also shows states spend more on seniors and people with disabilities than on the broader adult population insured by Medicaid, which is also true in Montana.

Nationally, states with expansions spend more money on people enrolled in Medicaid across eligibility groups compared with nonexpansion states, according to a KFF report.

Zoe Barnard, a senior adviser for Manatt who worked for Montana’s health department for nearly 10 years, said not only has the state’s uninsured rate dropped by 30% since it expanded Medicaid, but also some specialty services have grown as more people access care.

FGA has long lobbied nonexpansion states, including Texas, Kansas, and Mississippi, to leave Medicaid expansion alone. In February, an FGA representative testified in support of an Idaho bill that included an expansion repeal trigger if the state couldn’t meet a set of rules, including instituting work requirements and capping enrollment. The bill failed.

Paragon produced an analysis titled “Resisting the Wave of Medicaid Expansion,” and Blase testified to Texas lawmakers this year on the value of continuing to keep expansion out of the Lone Star State.

On the federal level, Paragon recently proposed a Medicaid overhaul plan to phase out the federal 90% matching rate for expansion enrollees, among other changes to cut spending. The left-leaning Center on Budget and Policy Priorities has countered that such ideas would leave more people without care.

In Montana, Republicans are defending a supermajority they didn’t have when a bipartisan group passed the expansion in 2015 and renewed it in 2019. Also unlike before, there’s now a Republican in the governor’s office. Gov. Greg Gianforte is up for reelection and has said the safety net is important but shouldn’t get too big.

Keenan, the Republican lawmaker, predicted the expansion debate won’t be clear-cut when legislators convene in January.

“Medicaid expansion is not a yes or no. It’s going to be a negotiated decision,” he said.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

The city of Beverly Hills has agreed to train its employees on abortion clinic protections after local officials interfered with the opening of an abortion clinic in “blatant” violation of state law, according to a proposed settlement to be unveiled Thursday by California Attorney General Rob Bonta.

Bonta’s office said the city’s then-mayor, city attorney, and city manager pressured DuPont Clinic’s landlord last spring to cancel the lease and that city officials also delayed permits to the clinic. They went so far as to warn the building owner that it could be liable for bomb threats and shootings at the medical office building in the wealthy city’s business district.

The Washington, D.C.-based reproductive health provider is one of a handful of clinics nationwide that advertise abortions past 28 weeks of gestation. It had secured a lease and begun preparations to open a second U.S. location in Beverly Hills.

Concerned about potential anti-abortion protests and negative media coverage, city officials “engaged in a pressure campaign under the guise of public safety,” according to Bonta’s complaint. The actions “blatantly violated” state law, Bonta said in the complaint. It’s the state’s first action under the voter-passed initiative known as Proposition 1, which enshrined abortion rights in the state constitution.

“It’s a stark reminder that there are efforts right here in California to undermine reproductive freedom,” Bonta said in an interview with KFF Health News ahead of the announcement. “These are city officials who took an oath to uphold the state constitution and state law, and they did the opposite.”

In signing the agreement, the city did not admit fault or liability. In a statement, Mayor Lester Friedman said the city disagreed with the allegations in the attorney general’s complaint.

“Beverly Hills is already home to medical facilities that offer complete reproductive health services,” Friedman said in a statement. “The city reaffirms and pledges that it did not and will not discriminate against any reproductive healthcare provider and strongly supports a woman’s right to choose.”

As part of the agreement which has been approved by the Beverly Hills City Council and must be approved by the Los Angeles County Superior Court, city officials will be required to train employees about state and federal protections for abortion clinics, create a protocol for handling complaints of potential violations, and appoint a “reproductive justice compliance officer” to manage the training program and materials.

California prohibits abortions past the point of fetal viability, around 24 weeks, except in cases in which the life or health of the woman is at risk. Proposition 1 strengthened reproductive freedom protections in the state constitution.

Approved by an overwhelming majority of statewide voters in 2022, the law says that the state, and by extension local governments, “shall not deny or interfere with an individual’s reproductive freedom in their most intimate decisions, which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives.”

Bonta said the measure, which at the time was widely regarded as a largely symbolic measure in deeply progressive California, provided a strong legal basis for the state’s case against the city of Beverly Hills and led directly to the settlement agreement.

“There are protections, both constitutional and statutory, that protect reproductive freedom in California,” Bonta said. “Cities need to honor and follow those rights and protections and when they’re not, we will get involved.”

DuPont Clinic had announced plans in October 2022 to expand to the Los Angeles area, according to Bonta’s office. The following month, flyers opposing the clinic’s opening appeared in and around the building.

Beverly Hills police officials later drafted a plan to send a letter to other tenants of the building warning them of the potential security risks, something Bonta said they’d never done with previous properties targeted by protesters.

The city attorney instructed city officials to not issue permits to DuPont until he’d spoken with the clinic about “whether the proposed use is allowed or not.” He later suggested DuPont provide a letter “confirming its intention to comply with California law” as it relates to abortions later in pregnancy.

“They acted differently and inserted themselves in delayed permits and launching a pressure campaign based on the fact that reproductive freedom is at stake,” Bonta said. “They targeted DuPont because of the fact that it provided fully legal reproductive health care.”

During a City Council meeting in April 2023, City Manager Nancy Hunt-Coffey sent an email to council members alerting them of the controversy over the new clinic, just before several activists spoke in opposition. The clinic could, she warned, “be the focus of protests, rallies and unfortunately other more violent actions on occasion.”

“How did this get through?” council member Sharona Nazarian immediately wrote back.

Hunt-Coffey replied: “Well, it’s a private business renting space in a private building.  We don’t have anything in our code that prevents it…”

What followed was a series of attempts by then-mayor Julian Gold, Hunt-Coffey, and the Beverly Hills police chief to stymie the clinic’s opening, Bonta said. Gold and the police chief met with building owner Douglas Emmett Inc., warning that the clinic could become a “lightning rod” for the city and that the landlord would be “responsible” and “liable” if anything were to happen. Gold also raised the possibility of bomb threats and active shooters, and the safety of other tenants in the building.

The clinic never opened.

Bonta said his office is prepared to go after local governments that shirk their responsibility to uphold state laws that protect abortion rights. He also suggested he would support amending state law to levy financial penalties on those who violate it.

If you dare, feast your eyes on this year’s winners of KFF Health News’ sixth annual Halloween Haiku contest. We received more than four dozen spooky submissions but only a few bubbled to the top of the cauldron. Here’s the winner and the top runners-up, illustrated by Oona Zenda. The judges’ favorites were inspired by blood shortages, high health care costs, and the eye-gouging price of prescription drugs. Keep an eye on KFF Health News’ social media accounts (X; Instagram; and Facebook) for more of our favorites. Enjoy!

1st Place

Vampires don’t scare me. 

Empty blood shelves, now that’s fear. 

Roll up, save a life.

— Crystal Decker 

2nd Place

What spooks me the most 

Is not a ghoul or a ghost 

But steep health care bills.

— Tom Cook 

3rd Place

No, not eye-gouging. 

My costume is scarier: 

Pharma price-gouging.

— Siri Palreddy

While Halloween may be coming to an end, KFF Health News reporting continues year-round. Send us your haikus at any time for possible inclusion in our Morning Briefing: https://kffhealthnews.org/contact-haiku/. 

When Cynthia Ruiz turns on her kitchen faucet, she hears a slight squeak before cloudy fluid bursts out of the spout. The water in her Central Valley town of East Orosi is clean enough most of the time to wash dishes, flush toilets, and take showers, but it’s not safe to swallow. Drinking water is trucked in twice a month.

“There are times where the water is so bad you can’t even wash dishes,” said Ruiz, who is advised not to drink the tap water, which is laden with nitrates — runoff from orange and nectarine fields surrounding the town of roughly 400. “We need help to fix our water problem.”

Tucked in a $10 billion climate bond on the November ballot is an earmark to improve drinking water quality for communities such as East Orosi. Proposition 4 would allocate $610 million for clean, safe, and reliable drinking water and require at least 40% be spent on projects that benefit vulnerable populations or disadvantaged communities. But it’s a fraction of what the state says is needed.

While most Californians have access to safe water, roughly 750,000 people as of late October are served by 383 failing water systems, many clustered in remote and sparsely populated areas. A June assessment by the California State Water Resources Control Board pegged the cost of repairing failing and at-risk public water systems at about $11.5 billion.

“We have communities in California that are served drinking water that has been out of compliance with regulatory standards for potent toxins like arsenic for years,” said Lara Cushing, an associate professor in UCLA’s Department of Environmental Health Sciences.

And climate change is eroding people’s access to clean water, she said. “There is kind of a perfect storm, if you will, of compounding hazards.”

Supporters say Proposition 4, to enact the Safe Drinking Water, Wildfire Prevention, Drought Preparedness, and Clean Air Bond Act of 2024, would jump-start upgrades by authorizing grants and loans for local governments to repair water systems contaminated with lead, arsenic, nitrates, or other chemicals tied to cancer, liver and kidney problems, and other serious health issues.

Water priorities vary by region, and the bond would give communities flexibility to address their needs, said MJ Kushner, a policy advocate at the Community Water Center, a statewide nonprofit. “It isn’t a one-size-fits-all solution,” Kushner said.

A taxpayer group opposing the bond says the state will go further into debt on piecemeal projects. It says the state is increasingly addressing its climate-related programs with bonds, which it calls the most expensive way for government to pay for things, rather than within the state budget.

Lawmakers in July added Proposition 4 to the ballot after Democratic Gov. Gavin Newsom, facing a $47 billion deficit, cut $6.6 billion in climate spending from the state budget, according to Department of Finance spokesperson H.D. Palmer. The reductions followed $3.1 billion in climate cuts Newsom and lawmakers enacted in 2023.

Susan Shelley, a spokesperson for the Howard Jarvis Taxpayers Association, said the state has already borrowed billions and that now isn’t the time to add more debt given the deficit.

“If the legislature chose to cut these from the budget, they should not go on the credit card,” Shelley said. “It’s irresponsible.”

According to the nonpartisan Legislative Analyst’s Office, the state has routinely allocated state funds for climate-related programs, with about 15% coming from bonds. The office estimates it would cost taxpayers $400 million a year for the next 40 years to repay the bond — a total of $16 billion.

Since 2000, California voters have approved eight water bonds totaling $27 billion, for projects involving flood management, habitat restoration, drought preparation, and drinking water improvement, according to the Public Policy Institute of California.

Scientists say climate change has led to more severe weather, including devastating floods and droughts; the spread of infectious diseases such as West Nile virus; and earlier deaths from respiratory illnesses. Public health experts add that as climate change worsens, its impact on people’s health will grow more severe and could cost the state more in the long run.

“If we quantify the damages associated with the do-nothing policy, you’ll see that typically, at the end of the day, the bill plus the interest costs are going to be less than the cost if we do nothing,” said Kurt Schwabe, an environmental economics and policy professor at the University of California-Riverside.

If approved, Ruiz hopes Proposition 4 can help East Orosi, a predominantly Latino and low-income community. Though she receives 25 gallons of drinking water twice a month, she sometimes runs out. The last time the 47-year-old drank tap water at home was when she was in high school.

“I don’t think any community anywhere in California should have to wait this long to get clean water,” Ruiz said.

CITRUS COUNTY, Fla. — It was hard enough for Stephanie to get methadone treatment when she moved to Florida from Indiana last year. The nearest clinic was almost an hour’s drive away and she couldn’t drive herself. But at least she didn’t have to worry about the cost of care.

As a parent with young children who was unable to find a job after moving, Stephanie qualified for Medicaid despite Florida’s tight eligibility rules. The state insurance program for people with low incomes or disabilities covers the methadone she needs to reduce her opioid cravings and prevent withdrawal sickness.

For nearly a decade, methadone has helped her hold down a job and take care of her kids. “Just have a normal, really normal, life,” said Stephanie, 39, who asked that her last name be withheld because her two youngest children don’t know about her history of opioid use disorder or that she has been in treatment for opioid addiction. “All the things that some people take for granted.”

So it was devastating for Stephanie when she visited her clinic in summer 2023 and learned she had been dropped from the state’s Medicaid rolls as the program worked to redetermine the eligibility of each enrollee. Suddenly, her methadone prescription cost much more than she could afford.

She panicked, afraid a disruption in care would trigger debilitating withdrawal symptoms like vomiting, fever, cramps, joint pain, and tremors. “That’s the first thing I thought,” she said. “I’m going to be so sick. How am I going to get up and take care of the kids?”

As of September, more than 25 million Americans — including 1.9 million Floridians — had lost Medicaid coverage since the expiration of federal covid-19 pandemic protections in March 2023 that had kept people continually enrolled. Among them were patients in treatment for opioid addiction, such as Stephanie, for whom a loss of coverage could be deadly.

Research shows that, when taken as prescribed, medications for opioid use disorder — such as methadone and a similar medicine, buprenorphine — can reduce dangerous drug use and cut overdose fatalities by more than half. Other studies have found the risk of overdose and death increases when treatment is interrupted.

It is unclear how many people with opioid addiction have lost coverage in the Medicaid disenrollment, known as the “unwinding.” But researchers at KFF, a health information nonprofit that includes KFF Health News, estimate that more than 1 million low-income Americans depend on the federal-state Medicaid program for lifesaving addiction care.

At Operation PAR — a nonprofit addiction treatment provider from which Stephanie and thousands of others along Florida’s Gulf Coast get care — the percentage of opioid treatment patients with Medicaid has dropped from 44 to 28 since the unwinding began last year, the organization said.

Dawn Jackson, who directs Operation PAR’s newest clinic, about an hour north of Tampa in the small Citrus County city of Inverness, said it has been a struggle trying to stretch limited grant dollars to cover the recent surge of uninsured patients.

“There’s been sleepless nights,” Jackson said. “We’re saving lives — we’re not handing out Happy Meals here.”

Methadone and buprenorphine are considered the gold standard of care for opioid addiction. The drugs work by binding to the brain’s opioid receptors to block cravings and withdrawal symptoms without making a person feel high. Treatment reduces illicit drug use and the accompanying overdose risk.

However, few Americans who could benefit from the medicines actually receive them: The latest federal data shows that in 2021 only about 1 in 5 people who needed the medicines got them. The low numbers offer a sharp contrast to the record-high drug overdose epidemic, which killed nearly 108,000 Americans in 2022 and is driven primarily by opioids.

Zachary Sartor, a family medicine doctor in Waco, Texas, who specializes in addiction treatment, described the effect of such medications as “nothing short of remarkable.”

“The evidence in the medical literature shows us that things like employment and quality of life overall increase with access to these medications, and that definitely bears out with what we see in the clinic,” Sartor said. “That benefit just seems to grow over time as people stay on medications.”

Sartor, who works at a safety net clinic, prescribes buprenorphine, and most of his patients are uninsured or on Medicaid. Some are among the 2.5 million Texans who lost coverage during the state’s unwinding, he said, causing their out-of-pocket buprenorphine costs to abruptly rise as much as fourfold.

The loss of coverage — which also cuts access to health care beyond addiction treatment — often requires patients to make risky trade-offs.

Sartor said that can mean patients having to choose between medications to treat their addiction and drugs for other medical conditions. “You start to see the cycle of patients having to ration their care,” he said.

Many people who lost their insurance in the Medicaid unwinding have since seen it reinstated. But even a brief disruption in care is serious for someone with opioid use disorder, said Maia Szalavitz, a journalist and an author who writes about addiction.

“If you want to save people’s lives and you have a lifesaving medication available, you don’t interrupt their access to health care,” Szalavitz said. “They end up in withdrawal and they end up dying.”

When Stephanie lost her Medicaid coverage last year, Operation PAR was able to subsidize her out-of-pocket methadone costs, so she paid only $30 a week. That was inexpensive enough for her to stick with treatment for the six months it took to restore her Medicaid coverage.

But the patchwork of federal and state grants that Operation PAR uses to cover uninsured patients doesn’t always meet demand, and waiting lists for subsidized methadone treatment are not uncommon, said Jackson, who directs the clinic in Citrus County.

Even before the Medicaid unwinding, about 13% of people younger than 65 in Florida were uninsured, one of the highest rates in the country, according to census data. Florida is also one of 10 states that have not expanded Medicaid for low-income adults.

Jon Essenburg, chief business officer at Operation PAR, said a recent infusion of opioid settlement money wiped out the group’s waiting lists, at least for now. But he said settlement dollars — Florida expects to receive $3.2 billion over 18 years from opioid manufacturers and distributors — are not a long-term solution to persistent coverage gaps, which is why stabler reimbursement sources like Medicaid can help.

“Turning people away over money is the last thing we want to do,” Jackson said. “But we also know that we can’t treat everybody for free.”

Stephanie is grateful she never had to go without her medicine.

“I don’t even want to think about what it would have been like if they wouldn’t have worked with me and helped me with the funding,” Stephanie said. “It would have been a very dark rabbit hole, I’m afraid.”

Kim Krisberg is a contributing writer for Public Health Watch and co-leads the reporting project The Holdouts. Stephanie Colombini is a reporter for WUSF’s Health News Florida project.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

When open enrollment for the Affordable Care Act, or Obamacare, starts nationwide this week, a group that had previously been barred from signing up will be eligible for the first time: The “Dreamers.” That’s the name given to children brought to the United States without immigration paperwork who have since qualified for the Deferred Action for Childhood Arrivals program.

Under a Biden administration rule that has become contentious in some states, DACA recipients will be able to enroll in — and, if their income qualifies, receive premium subsidies for — Obamacare coverage. The government estimates that about 100,000 previously uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, which is the sign-up season start date in all states except Idaho.

Yet the fate of the rule remains uncertain. It is being challenged in federal court by Kansas and 18 other states, including several in the South and Midwest, as well as Montana, New Hampshire, and North Dakota.

Separately, 19 states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many on the East and West coasts, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

The rule, finalized in May, clarifies that those who qualify for DACA will be considered “lawfully present” for the purpose of enrolling in plans under the ACA, which are open to American citizens and lawfully present immigrants.

“The rule change is super important as it corrects a long-standing and erroneous exclusion of DACA recipients from ACA coverage,” said Nicholas Espíritu, a deputy legal director for the National Immigration Law Center, which has also filed briefs in support of the government rule.

President Barack Obama established DACA in June 2012 by executive action to protect from deportation and provide work authorization to some unauthorized residents brought to the U.S. as children by their families if they met certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were a veteran.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The lawsuit, filed in August in U.S. District Court for the District of North Dakota, seeks to postpone the rule’s effective date and overturn it, saying the expansion of the “lawfully present” definition by the Biden administration violates the law.

On Oct. 15, U.S. District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, heard arguments in the case.

Plaintiff states are pushing for fast action, and it is possible a ruling will come in the days before open enrollment begins nationwide in November, said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

But the outlook is complicated.

For starters, in a legal battle like this, those who file a case must demonstrate the harm being alleged, such as additional costs the rule will force the states to absorb. There are only about 128 DACA recipients in North Dakota, where the case is being heard, and not all of them are likely to enroll in ACA insurance.

Furthermore, North Dakota is not among the states that run their own enrollment marketplace. It relies on the federal healthcare.gov site, which makes the legal burden harder to meet.

“Even though North Dakota does not pay any money to purchase ACA health care, they are still claiming somehow that they are harmed,” said Espíritu, at the immigration law center, which is representing several DACA recipients and CASA, a nonprofit immigrant advocacy group, in opposing the state efforts to overturn the rule.

During the hearing, Traynor focused on this issue and noted that a state running its own marketplace might be a better venue for such a case. He ordered the defendants to present more information by Oct. 29 and for North Dakota to respond by Nov. 12.

On Monday, the judge denied a motion from the federal government asking him to reconsider his order requiring it to provide the state with the names of 128 DACA recipients who live there, under seal, for the purpose of helping calculate any financial costs associated with their presence.

In addition, it’s possible the case will be transferred to another district court, but that could lead to delays in a decision, attorneys following the case said.

The judge also could take a number of directions in his decision. He could postpone the rule’s effective date, as requested in part of the lawsuit, preventing DACA recipients from enrolling in Obamacare while the case is decided. Or he could leave the effective date as it stands while the case proceeds.

With any decision, the judge could decide to apply the ruling nationally or limit it to just the states that challenged the government rule, Baron said.

“The approach taken by different judges has varied,” Baron said. “There has been a practice to vacate some regulatory provisions nationwide, but a lot of judges, including justices on the Supreme Court, also have cited concerns about individual judges being able to affect policy this way.”

Even as the case moves along, Espíritu said his organization is encouraging DACA recipients to enroll once the sign-up period begins nationally in November.

“It’s important to enroll as soon as possible,” he said, adding that organizations such as his will continue to monitor the case and give updates if the situation changes. “We know that getting access to good affordable health care can be transformative to people’s lives.”

DACA was created in 2012 by then-President Barack Obama. This case challenging the rule is wholly separate from another case, brought by some of the same states as those opposed to the ACA rule, seeking to entirely end the DACA program. That case is currently in the appeals process in federal court.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.