HELENA, Mont. — A final-minute change to a 2019 invoice put an finish date on Montana’s Medicaid enlargement program, setting the stage for what’s anticipated to be essentially the most vital well being care debate of the 2025 Montana Legislature.
In latest interviews, legislative leaders predicted a vigorous debate over maintaining the Medicaid enlargement program, which pays the medical payments of greater than 75,000 low-income Montanans at an annual value of about $1 billion to the federal and state governments. In addition they anticipate 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.
“All of it type of hyperlinks collectively,” mentioned state Sen. Dennis Lenz, a Billings Republican and chair of the Senate Public Well being, Welfare, and Security Committee.
Legislators from each events additionally anticipate lawmakers from the GOP majority to proceed to pursue abortion restrictions, regardless of a November statewide vote making abortion a proper beneath the Montana Structure.
The Medicaid enlargement debate, nevertheless, looms largest among the many well being care matters.
“That is undoubtedly the elephant within the room, so to talk,” mentioned Senate Minority Chief Pat Flowers, a Belgrade Democrat.
Montana expanded Medicaid, initially for 4 years, in 2015, by way of a coalition of minority Democrats, some average Republicans, and a Democratic governor. The same 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 yr’s legislature.
Republicans nonetheless maintain robust majorities within the state Home and Senate, whose leaders voiced issues concerning the enlargement program.
This time round, the governor — Greg Gianforte — is a Republican. Final yr, the Gianforte administration accomplished a postpandemic eligibility reassessment that reduce the variety of enlargement enrollees from a excessive of 125,000 folks in April and Could 2023 to roughly 76,600 folks as of October, the newest knowledge obtainable.
Gianforte has included funding for Medicaid enlargement in his proposed funds, which should be authorized by the legislature to take impact. His workplace mentioned he needs “robust work necessities for able-bodied adults with out dependents” to participate in this system. Spokesperson Kaitlin Value mentioned the governor “has been clear that the security web of Medicaid must be there for individuals who really want it, however that it’s going to 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 or not any enlargement invoice passes “will rely upon the folks pushing it,” mentioned Senate President Matt Regier, a Kalispell Republican who opposes enlargement. “If there isn’t any give-and-take, it could possibly be an attention-grabbing vote.”
Flowers mentioned he is aware of getting Medicaid enlargement by way of the Senate will likely be powerful. Republicans maintain a 32-18 majority, and the GOP caucus leans conservative.
“There are a number of my colleagues on the Republican aspect which can be ideologically opposed, and I believe you’re going to see that of their constant voting in opposition to reauthorizing,” Flowers mentioned.
Medicaid, funded by each the state and federal governments, gives well being protection for sure teams of low-income folks. Enlargement 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 yr for a person in 2024.
The 2010 federal Reasonably priced Care Act opened Medicaid to this new group of adults, beginning in 2014. However a 2012 U.S. Supreme Court docket ruling mentioned states may select whether or not to undertake the change, and 40 have carried out so.
Republican state Rep. Ed Buttrey mentioned he would sponsor a invoice to reauthorize Medicaid enlargement with out an expiration date, however many GOP lawmakers stay unconvinced that enlargement is required, viewing it as a pricey, pointless welfare program.
“I perceive there are some professionals to Medicaid enlargement, however, as a conservative, I do have points with — I assume I can’t get round it — socialized medication,” mentioned Home Speaker Brandon Ler (R-Savage).
In September, representatives from a pair of conservative-funded assume tanks made a case for ending Medicaid enlargement, saying its enrollment and prices are bloated. The consulting agency Manatt, however, mentioned extra folks have entry to vital remedy due to Medicaid enlargement.
In any case, it seems many Republicans need to require contributors to work, pay premiums, or meet different situations, if this system is to proceed.
Premiums and work necessities are in Montana’s legislation proper now. The Biden administration, although, nixed each, in order that they haven’t been in impact. Montana Republicans anticipate the incoming Trump administration to be extra open to such provisions.
Democrats say Medicaid enlargement has succeeded on many fronts: protecting hundreds of low-income staff, serving to maintain rural well being care suppliers and hospitals afloat, and bringing a whole bunch of tens of millions of federal {dollars} into Montana’s financial system. The state pays 10% of this system’s prices, which totaled about $962.4 million in fiscal yr 2024. The federal authorities picked up $870 million of that tab.
“With all that, it’s simply beautiful to me that there could possibly be opposition,” Flowers mentioned. “There’s simply no cause for us, collectively as a state, to not assist this.”
Democrats could have their very own enlargement invoice, introduced by Rep. Mary Caferro of Helena. She mentioned 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 places of work which have been closed. It additionally would make enlargement everlasting.
“We’re 10 years into this program,” mentioned Rep. SJ Howell of Missoula, the Democratic vice chair of the Home Human Companies Committee, which debates well being coverage laws. “I believe that persevering with a cycle of uncertainty for sufferers and suppliers doesn’t make sense.”
Legislators additionally see the enlargement debate tying into different well being care discussions.
Regier and Lenz mentioned Montana’s nonprofit hospitals — robust supporters of enlargement — have benefited drastically from this system and may have to present one thing again in return. One risk: extra authorities oversight of the “community benefits” that hospitals should present to obtain tax-exempt standing.
In addition they famous that Montanans pay a payment for hospital stays to assist the Medicaid program and {that a} payment on hospital outpatient income helps pay the prices of Medicaid enlargement. These charges and the ensuing cash raised for hospitals could benefit evaluate, they mentioned.
In the meantime, backers mentioned Medicaid enlargement 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 enlargement ends, many adults would lose entry to the psychological well being and habit remedy system that Gianforte needs to enhance, advocates mentioned, whereas remedy suppliers would lose a major income.
Cash for the behavioral well being modifications would come, partly, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals through the budgeting course of. Howell mentioned Democrats need to have a look at whether or not the modifications would use sufficient of the $300 million fund rapidly sufficient and on essentially the most urgent wants.
In the meantime, Republicans mentioned they’ll doubtless introduce payments on abortion — despite the fact that Montanans authorized Constitutional Initiative 128 by a 58-42 margin in November. CI-128 mentioned the fitting to an abortion can’t be “denied or burdened” besides by a “compelling authorities curiosity achieved by the least restrictive means.”
“It’s not going to gradual us down in our pro-life positions,” Ler mentioned of CI-128.
At a minimal, GOP leaders mentioned, a few of CI-128’s phrases must be outlined.
“With a really poorly written poll initiative like that, we have to say, ‘What does that abortion trade appear like beneath CI-128 and what’s our function as a state?’” Regier mentioned.
However state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Well being, Welfare, and Security Committee, mentioned the CI-128 vote offered a powerful mandate for the fitting of privateness.
Enacting restrictions would result in “that slippery slope of what’s subsequent, if we permit legislators to rule on what’s occurring within the physician’s workplace,” she mentioned. “What sort of can of worms could possibly be opened to different invasions of privateness?”
