HELENA, Mont. \u2014 A last-minute change to a 2019 bill put an end date on Montana\u2019s Medicaid expansion program, setting the stage for what is anticipated to be the most significant health care debate of the 2025 Montana Legislature. <\/p>\n
In recent interviews, legislative leaders predicted a vigorous debate over keeping the Medicaid expansion program, which pays the medical bills of more than 75,000 low-income Montanans at an annual cost of about $1 billion to the federal and state governments. They also expect the topic to seep into other health policy decisions, such as the approval of new spending on Montana\u2019s behavioral health system and regulation of hospital tax-exempt status.<\/p>\n
\u201cIt all kind of links together,\u201d said state Sen. Dennis Lenz, a Billings Republican and chair of the Senate Public Health, Welfare, and Safety Committee.<\/p>\n
Legislators from both parties also expect lawmakers from the GOP majority to continue to pursue abortion restrictions, despite a November statewide vote making abortion a right under the Montana Constitution.<\/p>\n
The Medicaid expansion debate, however, looms largest among the health care topics.<\/p>\n
\u201cThis is definitely the elephant in the room, so to speak,\u201d said Senate Minority Leader Pat Flowers, a Belgrade Democrat.<\/p>\n
Montana expanded Medicaid, initially for four years, in 2015, through a coalition of minority Democrats, some moderate Republicans, and a Democratic governor. A similar coalition renewed the program in 2019, but at the last moment, Senate Republicans tacked on an end date of June 30, 2025. That put the matter in the lap of this year\u2019s legislature.<\/p>\n
Republicans still hold strong majorities in the state House and Senate, whose leaders voiced concerns about the expansion program.<\/p>\n
This time around, the governor \u2014 Greg Gianforte \u2014 is a Republican. Last year, the Gianforte administration completed a postpandemic eligibility reassessment that cut the number of expansion enrollees from a high of 125,000 people in April and May 2023 to approximately 76,600 people as of October, the most recent data available.<\/p>\n
Gianforte has included funding for Medicaid expansion in his proposed budget, which must be approved by the legislature to take effect. His office said he wants \u201cstrong work requirements for able-bodied adults without dependents\u201d to take part in the program. Spokesperson Kaitlin Price said the governor \u201chas 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.\u201d<\/p>\n
GOP legislative leaders clearly are skeptical of the program, saying it won\u2019t continue without some \u201csideboards,\u201d or additional requirements of enrollees and providers.<\/p>\n
Whether any expansion bill passes \u201cwill depend on the people pushing it,\u201d said Senate President Matt Regier, a Kalispell Republican who opposes expansion. \u201cIf there is no give-and-take, it could be an interesting vote.\u201d<\/p>\n
Flowers said he knows getting Medicaid expansion through the Senate will be tough. Republicans hold a 32-18 majority, and the GOP caucus leans conservative.<\/p>\n
\u201cThere are a lot of my colleagues on the Republican side that are ideologically opposed, and I think you\u2019re going to see that in their consistent voting against reauthorizing,\u201d Flowers said.<\/p>\n
Medicaid, funded by both the state and federal governments, provides health coverage for certain groups of low-income people. Expansion extended Medicaid coverage to nondisabled adults ages 19 to 64 with incomes up to 138% of the federal poverty level \u2014 about $20,800 a year for an individual in 2024.<\/p>\n
The 2010 federal Affordable Care Act opened Medicaid to this new group of adults, starting in 2014. But a 2012 U.S. Supreme Court ruling said states could choose whether to adopt the change, and 40 have done so.<\/p>\n
Republican state Rep. Ed Buttrey said he would sponsor a bill to reauthorize Medicaid expansion without an expiration date, but many GOP lawmakers remain unconvinced that expansion is needed, viewing it as a costly, unnecessary welfare program.<\/p>\n
\u201cI understand there are some pros to Medicaid expansion, but, as a conservative, I do have issues with \u2014 I guess I can\u2019t get around it \u2014 socialized medicine,\u201d said House Speaker Brandon Ler (R-Savage).<\/p>\n
In September, representatives from a pair of conservative-funded think tanks made a case for ending Medicaid expansion, saying its enrollment and costs are bloated<\/a>. The consulting firm Manatt, on the other hand, said more people have access to critical treatment because of Medicaid expansion.<\/p>\n At the least, it appears many Republicans want to require participants to work, pay premiums, or meet other conditions, if the program is to continue.<\/p>\n Premiums and work requirements are in Montana\u2019s law right now. The Biden administration, though, nixed both, so they haven\u2019t been in effect. Montana Republicans expect the incoming Trump administration to be more open to such provisions.<\/p>\n Democrats say Medicaid expansion has succeeded on many fronts: covering thousands of low-income workers, helping keep rural health care providers and hospitals afloat, and bringing hundreds of millions of federal dollars into Montana\u2019s economy. The state pays 10% of the program\u2019s costs, which totaled about $962.4 million in fiscal year 2024. The federal government picked up $870 million of that tab.<\/p>\n \u201cWith all that, it\u2019s just stunning to me that there could be opposition,\u201d Flowers said. \u201cThere is just no reason for us, collectively as a state, not to support this.\u201d<\/p>\n Democrats will have their own expansion bill, brought by Rep. Mary Caferro of Helena. She said the bill would remove the work requirements and premiums, shine more light on the contracting activities of the state health department, and reopen some public assistance offices that have been closed. It also would make expansion permanent.<\/p>\n \u201cWe\u2019re 10 years into this program,\u201d said Rep. SJ Howell of Missoula, the Democratic vice chair of the House Human Services Committee, which debates health policy legislation. \u201cI think that continuing a cycle of uncertainty for patients and providers doesn\u2019t make sense.\u201d<\/p>\n Legislators also see the expansion debate tying into other health care discussions.<\/p>\n Regier and Lenz said Montana\u2019s nonprofit hospitals \u2014 strong supporters of expansion \u2014 have benefited greatly from the program and may need to give something back in return. One possibility: more government oversight of the \u201ccommunity benefits\u201d<\/a> that hospitals must provide to receive tax-exempt status.<\/p>\n They also noted that Montanans pay a fee for hospital stays to support the Medicaid program and that a fee on hospital outpatient revenue helps pay the costs of Medicaid expansion. Those fees and the resulting money raised for hospitals may merit review, they said.<\/p>\n Meanwhile, backers said Medicaid expansion underpins one of the governor\u2019s major policy priorities, to improve the state\u2019s behavioral health system. Gianforte has proposed spending up to $100 million over the next two years on 10 recommendations made by an advisory commission that reviewed the system for the past 18 months.<\/p>\n If Medicaid expansion ends, many adults would lose access to the mental health and addiction treatment system that Gianforte wants to improve, advocates said, while treatment providers would lose a significant source of revenue.<\/p>\n Money for the behavioral health changes would come, in part, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte\u2019s proposals during the budgeting process. Howell said Democrats want to look at whether the changes would use enough of the $300 million fund quickly enough and on the most pressing needs.<\/p>\n Meanwhile, Republicans said they\u2019ll likely introduce bills on abortion \u2014 even though Montanans approved Constitutional Initiative 128 by a 58-42 margin in November. CI-128 said the right to an abortion cannot be \u201cdenied or burdened\u201d except by a \u201ccompelling government interest achieved by the least restrictive means.\u201d<\/p>\n \u201cIt\u2019s not going to slow us down in our pro-life positions,\u201d Ler said of CI-128.<\/p>\n At a minimum, GOP leaders said, some of CI-128\u2019s terms should be defined.<\/p>\n \u201cWith a very poorly written ballot initiative like that, we need to say, \u2018What does that abortion industry look like under CI-128 and what\u2019s our role as a state?\u2019\u201d Regier said.<\/p>\n But state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Health, Welfare, and Safety Committee, said the CI-128 vote provided a strong mandate for the right of privacy.<\/p>\n Enacting restrictions would lead to \u201cthat slippery slope of what\u2019s next, if we allow legislators to rule on what\u2019s happening in the doctor\u2019s office,\u201d she said. \u201cWhat kind of can of worms could be opened to other invasions of privacy?\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n