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 essentially the most vital well being care debate of the 2025 Montana Legislature.
In current interviews, legislative leaders predicted a vigorous debate over holding 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. In addition they anticipate the subject to seep into different well being coverage choices, such because the approval of recent spending on Montana’s behavioral well being system and regulation of hospital tax-exempt standing.
“All of it sort 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 underneath the Montana Structure.
The Medicaid growth debate, nevertheless, looms largest among the many well being care subjects.
“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 means 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 sturdy majorities within the state Home and Senate, whose leaders voiced issues in regards to the growth program.
This time round, the governor — Greg Gianforte — is a Republican. Final yr, the Gianforte administration accomplished a postpandemic eligibility reassessment that minimize the variety of growth enrollees from a excessive of 125,000 folks in April and Might 2023 to roughly 76,600 folks as of October, the latest information obtainable.
Gianforte has included funding for Medicaid growth in his proposed price range, which have to be authorized by the legislature to take impact. His workplace mentioned he desires “sturdy 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 protection internet of Medicaid needs to be there for many who really want it, however that it’ll 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 growth invoice passes “will rely on the folks pushing it,” mentioned Senate President Matt Regier, a Kalispell Republican who opposes growth. “If there isn’t a give-and-take, it might be an attention-grabbing vote.”
Flowers mentioned he is aware of getting Medicaid growth by means of the Senate will likely be powerful. Republicans maintain a 32-18 majority, and the GOP caucus leans conservative.
“There are lots of my colleagues on the Republican facet which are ideologically opposed, and I believe you’re going to see that of their constant voting towards reauthorizing,” Flowers mentioned.
Medicaid, funded by each the state and federal governments, supplies well being protection for sure teams of low-income folks. Growth prolonged Medicaid protection to nondisabled adults ages 19 to 64 with incomes as much as 138% of the federal poverty stage — about $20,800 a yr for a person in 2024.
The 2010 federal Inexpensive Care Act opened Medicaid to this new group of adults, beginning in 2014. However a 2012 U.S. Supreme Courtroom ruling mentioned states may select whether or not to undertake the change, and 40 have executed so.
Republican state Rep. Ed Buttrey mentioned 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 pricey, pointless welfare program.
“I perceive there are some professionals to Medicaid growth, 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 suppose tanks made a case for ending Medicaid growth, saying its enrollment and prices are bloated. The consulting agency Manatt, however, mentioned extra folks have entry to crucial remedy due to Medicaid growth.
As a minimum, it seems many Republicans wish 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, so that they haven’t been in impact. Montana Republicans anticipate the incoming Trump administration to be extra open to such provisions.
Democrats say Medicaid growth has succeeded on many fronts: protecting 1000’s of low-income employees, serving to preserve 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 yr 2024. The federal authorities picked up $870 million of that tab.
“With all that, it’s simply gorgeous to me that there might be opposition,” Flowers mentioned. “There may be simply no purpose for us, collectively as a state, to not assist this.”
Democrats can have their very own growth invoice, introduced by Rep. Mary Caferro of Helena. She mentioned the invoice would take away the work necessities and premiums, shine extra gentle on the contracting actions of the state well being division, and reopen some public help workplaces which have been closed. It additionally would make growth everlasting.
“We’re 10 years into this program,” mentioned Rep. SJ Howell of Missoula, the Democratic vice chair of the Home Human Providers 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 growth debate tying into different well being care discussions.
Regier and Lenz mentioned Montana’s nonprofit hospitals — sturdy supporters of growth — have benefited vastly from this system and might have to provide one thing again in return. One chance: 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 growth. These charges and the ensuing cash raised for hospitals could advantage evaluation, they mentioned.
In the meantime, backers mentioned 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 subsequent 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 habit remedy system that Gianforte desires to enhance, advocates mentioned, whereas remedy suppliers would lose a big income.
Cash for the behavioral well being adjustments 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 wish to have a look at whether or not the adjustments 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 — though Montanans authorized Constitutional Initiative 128 by a 58-42 margin in November. CI-128 mentioned the appropriate 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 sluggish 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 needs to be outlined.
“With a really poorly written poll initiative like that, we have to say, ‘What does that abortion trade appear like underneath 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 supplied a powerful mandate for the appropriate of privateness.
Enacting restrictions would result in “that slippery slope of what’s subsequent, if we enable legislators to rule on what’s occurring within the physician’s workplace,” she mentioned. “What sort of can of worms might be opened to different invasions of privateness?”
