Aided by a former North Dakota Congressman and a previous federal health official, a loosely knit advocacy group is raising an alert over what it says is a threat flying under the radar of most state residents.

Former Congressman Earl Pomeroy and Mary Wakefield, past deputy secretary of U.S. Department of Health and Human Services, are helping the ad hoc Dakotans for Health rally the grassroots against a 20-state lawsuit led by Texas to declare the Affordable Care Act, informally known as Obamacare, unconstitutional. North and South Dakota are among states that have joined the lawsuit.

Wakefield, a nurse, is former director of the Center for Rural Health at the University of North Dakota and a past federal official during the Obama Administration.

Pomeroy, an attorney, served as North Dakota’s insurance commissioner and as U.S. Congressman from 1993 to 2011.

Pomeroy said he felt the need to make people aware of the Texas lawsuit after U.S. Attorney General Jeff Sessions announced in early June that he was taking the unusual position to not defend the ACA in court.

“They look to take away by lawsuit what they were unable to do legislatively,” Pomeroy said.

He said many North Dakotans have not heard about the lawsuit.

“North Dakotans don’t know their Attorney General has filed a lawsuit to take away the law that’s provided insurance coverage to 40,000 North Dakotans,” Pomeroy said. “What’s really important is ultimately the voters have this information so they can form their own opinion in this election year.”

He said the push is to create awareness and encourage voters to ask candidates about their stance on the lawsuit.

About half of the 40,000 North Dakotans benefiting from ACA are covered by Expanded Medicaid, according to Pomeroy and Wakefield. Others are covered through premium subsidies or through insurance previously not available due to pre-existing conditions. Additional North Dakotans are covered through the Children’s Health Insurance Program and through an ACA provision allowing youth to remain on parents’ insurance to age 26.

Wakefield added the ACA is critical to rural hospitals, which are operating on thin margins. Since 2010, 84 rural hospitals across the United States have closed – the vast majority in states that did not expand Medicaid, she said.

Rural residents also have a higher rate of chronic illness and would be hurt if insurance companies are allowed to once again restrict coverage or charge more for pre-existing conditions, she said.

“That’s taking us back to the bad old days,” Wakefield said. “This is serious because it plays politics with people’s health.”

The U.S. Supreme Court previously ruled the ACA’s mandated coverage was constitutional under the taxing power of Congress. Last year’s Republican-led tax overhaul law removed the financial penalty for not buying health insurance, starting in 2019. The Texas lawsuit argues that without the financial penalty, the individual mandate no longer can be considered a tax and is therefore unconstitutional. With no mandate penalty, the lawsuit argues the entire law is no longer workable.

The North Dakota Attorney General’s Office had not issued a statement in joining the lawsuit and declined Monday to comment, stating the Texas lawsuit speaks for itself.

Pomeroy said it’s clear the intent of Congress was to repeal the mandate and not the remainder of the law.

“We feel very strongly that’s an appropriate law,” Pomeroy said. “We don’t think it’s unconstitutional for there to be a law protecting people against insurance companies.”

Dakotans for Health, a group of North and South Dakotans focused on maintaining provisions of the ACA, recently released the North Dakota Rural Health Report.

Data in the state report includes:

– decline in uninsured rate from 12.1 to 8.9 between 2013 and 2016.

– 11 percent of residents in rural areas served by Medicaid.

– $46 million reduction in uncompensated care costs from 2013 to 2015.

– 22,500 North Dakotans enrolled in insurance through the ACA Marketplace.