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 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 form 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 growth debate, nevertheless, looms largest among the many well being care matters.
“That is positively 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 a coalition of minority Democrats, some reasonable 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 growth program.
This time round, the governor — Greg Gianforte — is a Republican. Final yr, the Gianforte administration accomplished a postpandemic eligibility reassessment that lower 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 newest knowledge accessible.
Gianforte has included funding for Medicaid growth in his proposed price range, which should be accepted by the legislature to take impact. His workplace mentioned he desires “robust work necessities for able-bodied adults with out dependents” to participate in this system. Spokesperson Kaitlin Worth mentioned the governor “has been clear that the security internet of Medicaid needs to be there for individuals who actually 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 received’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 any give-and-take, it may very well be an attention-grabbing vote.”
Flowers mentioned he is aware of getting Medicaid growth by the Senate will likely be robust. Republicans maintain a 32-18 majority, and the GOP caucus leans conservative.
“There are a variety 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. Enlargement 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 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 finished 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 expensive, pointless welfare program.
“I perceive there are some execs to Medicaid growth, however, as a conservative, I do have points with — I suppose I can’t get round it — socialized drugs,” mentioned Home 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, alternatively, mentioned extra folks have entry to vital therapy due to Medicaid growth.
As a minimum, it seems many Republicans wish to require members 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 growth has succeeded on many fronts: protecting 1000’s of low-income staff, serving to maintain rural well being care suppliers and hospitals afloat, and bringing tons of of thousands and thousands 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 may very well be opposition,” Flowers mentioned. “There may be simply no motive for us, collectively as a state, to not help this.”
Democrats may 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 mild 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 — robust supporters of growth — have benefited enormously from this system and might have to present one thing again in return. One chance: extra authorities oversight of the “neighborhood advantages” that hospitals should present to obtain tax-exempt standing.
In addition they famous that Montanans pay a payment for hospital stays to help 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 evaluate, 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 dependancy therapy system that Gianforte desires to enhance, advocates mentioned, whereas therapy suppliers would lose a major income.
Cash for the behavioral well being adjustments would come, partially, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals throughout the budgeting course of. Howell mentioned Democrats wish to take a look at whether or not the adjustments would use sufficient of the $300 million fund shortly sufficient and on essentially the most urgent wants.
In the meantime, Republicans mentioned they’ll possible introduce payments on abortion — though Montanans accepted Constitutional Initiative 128 by a 58-42 margin in November. CI-128 mentioned the proper 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 seem like beneath CI-128 and what’s our position 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 robust mandate for the proper 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 may very well be opened to different invasions of privateness?”
