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The news that the Republican effort to repeal and replace Obamacare had failed brought relief, at least temporarily, for health care providers who had been bracing for the possibility of deep cuts in Medicaid funding.

The divisive debate over GOP plans to dismantle much of Obamacare has highlighted the importance of Medicaid in Hawaii as a crucial lifeline for people who are low-income, disabled or elderly.

About 110,000 people in the state have gained health care coverage since 2010 because of the expansion of the Medicaid program under Obamacare. The expansion provided Hawaii with an additional $230 million a year from the federal government to pay the costs of their health coverage.

A total of about 350,000 people in the state are currently on Medicaid.

For Hawaii residents with chronic problems, cuts in Medicaid funding would have dramatic impacts.

About 25 percent of Medicaid patients here have mental health problems, 25 percent have diabetes and about one-third are struggling with substance abuse. In nursing homes, about 50 percent to 70 percent of all patients are on Medicaid.

For Sheila Beckham, chief executive officer of Waikiki Health, which operates seven outpatient clinics in Honolulu and provided care to 11,000 low-income patients last year, the worry began six months ago after Donald Trump was elected president.

Once it became clear that Trump intended to press forward with his campaign pledge to repeal and replace Obamacare, and Republican lawmakers in Washington announced their own proposals, Beckham realized she needed to put together a worst-case scenario.

She considered closing all but two of the clinics she operates, which would mean shuttering Care-A-Van on Waialae Avenue, the PATH Clinic on 22nd Avenue and the Youth Outreach center at 415 Keoniana St. Those plans would have required layoffs of 80 to 100 employees. It also meant that some 6,000 of her patients might lose their coverage, she said.

So Beckham was heartened by the news earlier this week that the most had faltered after a growing number of Republican Senators opposed the plan.

Listen to an interview with Judy Mohr Peterson, director of Hawaii’s Medicaid program: 

The Senate plan pushed by Majority Leader Mitch McConnell would have imposed caps on Medicaid spending, saving billions of dollars but eliminating insurance coverage for millions of people. An eventual rollback of the Medicaid expansion was also opposed by several Republican governors.

In a series of acerbic tweets, President Trump criticized both Republican and Democrats for the failure to reach an agreement. But he also suggested a bipartisan bill might be the way to go in the future.

The delay is encouraging for local Medicaid supporters.

“Right now, I’m hopeful, and each day that we move forward without a vote brings us closer to the possibility of a bipartisan bill that’s good for everyone,” Beckham said.

Judy Mohr Peterson, the state’s Medicaid director, also spent the six months considering how to cope with any cuts in federal funding and the potential for what she called for what she called “draconian” impacts on Medicaid beneficiaries in the state.

She and other state officials had determined that they would not have permitted anyone to lose coverage immediately, but they knew it would be difficult and expensive for Hawaii to solve any long-term problems created by big reductions in . federal support.

The debate about Medicaid’s future will continue, both here and in Washington, she said.

“We are pleased that the bill will not move forward,” she said. “We believe the best solution will be thoughtful, bipartisan and one that is a partnership between federal and state leadership. We will continue to focus on helping all of Hawaii’s residents have access to quality healthcare.”

State legislators have also been anxiously keeping an eye on the political wrangling in Washington.

“Obamacare has been very important for Hawaii,” said state Sen. Josh Green, a practicing emergency room doctor on the Big Island, who chairs the human services committee at the state legislature. “It’s enabled us to take our uninsured rate from about 9 percent down to about 4 percent.”

Green said he has witnessed first-hand the impact of Obamacare on Hawaii.

“I see people all the time who would not be able to get health care if it were not for the expansion,” he said. “It can make a big change in places like the emergency room, where people really need care, but it can be quite expensive… It’s a game changer for many people who have experienced poverty recently or have minimal assets.”

“Now people don’t have to worry about going bankrupt if they need medical care, especially expensive surgery or emergency care.”

One out of every four Hawaii citizens, he says, is on Medicaid—and in some rural districts, the number is much higher.

Where are Hawaii’s Health Centers?

Medicaid coverage has become increasingly important for Hawaii’s hospitals and health clinics, according to statistics from the federal .

In 2010, at Waikiki Health, about 54 percent of all patients were uninsured, but that number fell to 22 percent in 2015, as Medicaid covered nearly half the patients.

At West Hawaii Community Health Center on the Big Island, Medicaid provided insurance for 63 percents of patients in 2015, compared to 58 percent in 2010.

Hospital administrator Merilyn Harris of Kau Hospital on the Big Island said last week that much of her concern was focused on what could happen to elderly and disabled people who might lose access to nursing home care if Medicaid funding was shrunk by the federal government.

“Most patients who are in long term care, if not initially, eventually end up on Medicaid,” she says. “In our district, probably 90 to 95 percent of our long-term care admissions are patients who are on Medicaid.”

She explained that Medicare, the program that provide health coverage to people age 65 and older, doesn’t cover long term care, and people are required to spend down their assets to gain access to a nursing home.

She has seen people go through $100,000 in savings, using up the money on health care costs, before Medicaid finally kicks in as a last resort to cover the costs of their dying days.

The thought of the government taking that last layer of protection away from aging people seems incomprehensible to her.

“If you think of it in a civilized society, its hard to understand,” she said.