Mike Dennison and Sue O’Connell
HELENA, Mont. — A final-minute change to a 2019 invoice put an finish date on Montana’s Medicaid growth program, setting the stage for what’s anticipated to be probably the most important well being care debate of the 2025 Montana Legislature.
In latest interviews, legislative leaders predicted a vigorous debate over retaining the Medicaid growth program, which pays the medical payments of greater than 75,000 low-income Montanans at an annual price of about $1 billion to the federal and state governments. They additionally count on the subject to seep into different well being coverage selections, such because the approval of recent spending on Montana’s behavioral well being system and regulation of hospital tax-exempt standing.
“It all kind of links together,” stated state Sen. Dennis Lenz, a Billings Republican and the chair of the Senate Public Health, Welfare, and Safety Committee.
Legislators from each events additionally count on lawmakers from the GOP majority to proceed to pursue abortion restrictions, regardless of a November statewide vote making abortion a proper underneath the Montana Constitution.
The Medicaid growth debate, nevertheless, looms largest among the many well being care subjects.
“This is definitely the elephant in the room, so to speak,” stated Senate Minority Leader Pat Flowers, a Belgrade Democrat.
Montana expanded Medicaid, initially for 4 years, in 2015, via a coalition of minority Democrats, some reasonable Republicans, and a Democratic governor. An analogous coalition renewed this system in 2019, however on the final second, Senate Republicans tacked on an finish date of June 30, 2025. That put the matter within the lap of this 12 months’s legislature.
Republicans nonetheless maintain robust majorities within the state House and Senate, whose leaders voiced considerations in regards to the growth program.
This time round, the governor — Greg Gianforte — is a Republican. Last 12 months, the Gianforte administration accomplished a postpandemic eligibility reassessment that reduce the variety of growth enrollees from a excessive of 125,000 folks in April and May 2023 to roughly 76,600 folks as of October, the newest information accessible.
Gianforte has included funding for Medicaid growth in his proposed funds, which should be authorized by the legislature to take impact. His workplace stated he desires “strong work requirements for able-bodied adults without dependents” to participate in this system. Spokesperson Kaitlin Price stated the governor “has been clear that the safety net of Medicaid should be there for those who truly need it, but that it will collapse if all are allowed to climb on it.”
GOP legislative leaders clearly are skeptical of this system, saying it gained’t proceed with out some “sideboards,” or further necessities of enrollees and suppliers.
Whether any growth invoice passes “will depend on the people pushing it,” stated Senate President Matt Regier, a Kalispell Republican who opposes growth. “If there is no give-and-take, it could be an interesting vote.”
Flowers stated he is aware of getting Medicaid growth via the Senate will likely be robust. Republicans maintain a 32-18 majority, and the GOP caucus leans conservative.
“There are a lot of my colleagues on the Republican side that are ideologically opposed, and I think you’re going to see that in their consistent voting against reauthorizing,” Flowers stated.
Medicaid, funded by each the state and federal governments, offers well being protection for sure teams of low-income folks. Expansion prolonged Medicaid protection to nondisabled adults ages 19 to 64 with incomes as much as 138% of the federal poverty degree — about $20,800 a 12 months for a person in 2024.
The 2010 federal Affordable Care Act opened Medicaid to this new group of adults, beginning in 2014. But a 2012 U.S. Supreme Court ruling stated states may select whether or not to undertake the change, and 40 have accomplished so.
Republican state Rep. Ed Buttrey stated he would sponsor a invoice to reauthorize Medicaid growth with out an expiration date, however many GOP lawmakers stay unconvinced that growth is required, viewing it as a expensive, pointless welfare program.
“I understand there are some pros to Medicaid expansion, but, as a conservative, I do have issues with — I guess I can’t get around it — socialized medicine,” stated House Speaker Brandon Ler (R-Savage).
In September, representatives from a pair of conservative-funded assume tanks made a case for ending Medicaid growth, saying its enrollment and prices are bloated. The consulting agency Manatt, however, stated extra folks have entry to vital remedy due to Medicaid growth.
At the least, it seems many Republicans need to require individuals to work, pay premiums, or meet different situations, if this system is to proceed.
Premiums and work necessities are in Montana’s regulation proper now. The Biden administration, although, nixed each, so that they haven’t been in impact. Montana Republicans count on the incoming Trump administration to be extra open to such provisions.
Democrats say Medicaid growth has succeeded on many fronts: protecting hundreds of low-income staff, serving to hold rural well being care suppliers and hospitals afloat, and bringing a whole lot of hundreds of thousands of federal {dollars} into Montana’s economic system. The state pays 10% of this system’s prices, which totaled about $962.4 million in fiscal 12 months 2024. The federal authorities picked up $870 million of that tab.
“With all that, it’s just stunning to me that there could be opposition,” Flowers stated. “There is just no reason for us, collectively as a state, not to support this.”
Democrats may have their very own growth invoice, introduced by Rep. Mary Caferro of Helena. She stated the invoice would take away the work necessities and premiums, shine extra mild on the contracting actions of the state well being division, and reopen some public help workplaces which were closed. It additionally would make growth everlasting.
“We’re 10 years into this program,” stated Rep. SJ Howell of Missoula, the Democratic vice chair of the House Human Services Committee, which debates well being coverage laws. “I think that continuing a cycle of uncertainty for patients and providers doesn’t make sense.”
Legislators additionally see the growth debate tying into different well being care discussions.
Regier and Lenz stated Montana’s nonprofit hospitals — robust supporters of growth — have benefited drastically from this system and may have to offer one thing again in return. One chance: extra authorities oversight of the “community benefits” that hospitals should present to obtain tax-exempt standing.
They additionally famous that Montanans pay a charge for hospital stays to assist the Medicaid program and {that a} charge on hospital outpatient income helps pay the prices of Medicaid growth. Those charges and the ensuing cash raised for hospitals could advantage assessment, they stated.
Meanwhile, backers stated Medicaid growth underpins one of many governor’s main coverage priorities, to enhance the state’s behavioral well being system. Gianforte has proposed spending as much as $100 million over the following two years on 10 suggestions made by an advisory fee that reviewed the system for the previous 18 months.
If Medicaid growth ends, many adults would lose entry to the psychological well being and dependancy remedy system that Gianforte desires to enhance, advocates stated, whereas remedy suppliers would lose a major income.
Money for the behavioral well being modifications would come, partially, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals in the course of the budgeting course of. Howell stated Democrats need to take a look at whether or not the modifications would use sufficient of the $300 million fund shortly sufficient and on probably the most urgent wants.
Meanwhile, Republicans stated they’ll possible introduce payments on abortion — although Montanans authorized Constitutional Initiative 128 by a 58-42 margin in November. CI-128 stated the appropriate to an abortion can’t be “denied or burdened” besides by a “compelling government interest achieved by the least restrictive means.”
“It’s not going to slow us down in our pro-life positions,” Ler stated of CI-128.
At a minimal, GOP leaders stated, a few of CI-128’s phrases needs to be outlined.
“With a very poorly written ballot initiative like that, we need to say, ‘What does that abortion industry look like under CI-128 and what’s our role as a state?’” Regier stated.
But state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Health, Welfare, and Safety Committee, stated the CI-128 vote supplied a robust mandate for the appropriate of privateness.
Enacting restrictions would result in “that slippery slope of what’s next, if we allow legislators to rule on what’s happening in the doctor’s office,” she stated. “What kind of can of worms could be opened to other invasions of privacy?”
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