Craig Gambrel slipped on a boat in August 2011, rupturing a disk in his back. Moving in certain ways sends shock waves through his body. It’s incredibly painful, and Gambrel is reluctant to take pain medications, though he sometimes does.

The surgery he finally got last Friday is expected to fix it.

But it’s been a struggle for the 35-year-old mechanical engineer, who worked installing radiant heating systems. The Belgrade husband and father of two hasn’t been able to work since two days after his accident. On that day, he passed out while removing a ladder from his truck and spent nearly an hour lying in the middle of a road.

Now the family relies on Gambrel’s common-law wife Laura Rasmussen’s $1,000 monthly paycheck from the casino where she works. They’ve given up cellphones, birthday celebrations, trips to the river and camping because they can’t afford the gas. They lost thousands in a rent-to-own agreement they were forced abandon to move into a smaller, less expensive rental home.

A proud man, Gambrel is frustrated he’s had to ask for help in the form of food stamps and from social service agencies.

“I’ve always supported myself,” he said, sitting in Lewis and Clark Park in Belgrade this week as his 2- and 3-year-old children played nearby. “I’ve always supported myself. Not being able to be fixed and support my family, it’s a killer.

“Pride only goes so far,” he added. “If you’ve got kids, pride goes out the door.”

Gambrel has been fighting two years to find the means to pay for the surgery he hopes will get him back to work. Thanks to Dr. Eugen Dolan, who agreed to do the surgery without considering Gambrel’s ability to pay, Gambrel was recovering Friday afternoon in a Billing hospital.

Though his children have insurance under the state’s Montana Healthy Kids program, he and his wife remain uninsured.

In Montana, Medicaid covers only children, pregnant women and disabled people. That leaves tens of thousands of Montanans without health insurance.

Gambrel is just one of between 50,000 and 60,000 of the 250,000 uninsured Montanans who would be eligible for Medicaid expansion under the Affordable Care Act, said Richard Opper, director of the Montana Department of Health and Human Services in Helena.

After the U.S. Supreme Court ruled that federally mandated Medicaid expansion was unconstitutional and should be determined by state governments, Montana’s lawmakers balked at doing so, angering Gov. Steve Bullock and many health care providers around the state.

“Montana is going to stay stuck in our broken system,” said Lander Cooney, CEO of Community Health Partners, based in Livingston.

Legislators opposing expansion say it will cost the state too much. They don’t trust the federal government will keep its promises to pay up to 90 percent of claims under the increased coverage. They believe expansion will simply line the pockets of thriving hospitals.

But proponents say expansion will cover thousands of uninsured Montanans who, like Gambrel, will fall into a doughnut hole under the Affordable Care Act – too wealthy to be eligible for Medicaid but too poor to afford individual insurance policies, even with federal subsidies.

Advocates also claim expansion will create jobs, generate local and state tax revenue and drive health care costs down.

As director of Gallatin Mental Health Center in Bozeman, Scott Malloy is worried that funding for his clients is drying up. The center provided upwards of $300,000 in charity care to mentally ill patients last year.

“But you can only do that so long before you can limit how much you can do and how many people you can see,” he said. “We’re not there yet, but I’m concerned that we’ll have the issue of people not getting in when they need to. I don’t want to get to the point where we tell people come in in six weeks.”

Malloy and others say a lack of preventive care results in higher health care costs. As with any illness, mental illness can escalate with time, requiring more expensive and often uncompensated emergency care.

The current system is “driving people from health care to sick care,” Opper said.

Between 50 and 60 percent of the center’s 2,000-plus clients are on Medicaid or have coverage under Montana’s Mental Health Service Program — a state-funded program that covers people with severe and chronic mental illness who live at or below 150 percent of the poverty level. If Medicaid were expanded to cover more of the center’s clients, it would free up more of the state’s money to treat others, Malloy said.

About 60 percent of Community Health Partners’ 12,000 annual patient visits are with uninsured clients. Most of them would qualify for insurance under Medicaid expansion, Cooney said.

And like Gambrel, most of CHP’s clients are working families, said Gallatin City-County Health Officer Matt Kelley.

“They’re construction workers, they serve us food in restaurants, they make the beds in our hotels, they are veterans,” Kelly said. “It’s too bad our legislators couldn’t find a way for those people to participate in our health care system.”

Under Medicaid expansion, the federal government will pay 100 percent of expanded Medicaid claims for the first year with states incrementally picking up more of the tab each year until 2020, when the federal government’s payments will drop to 90 percent.

As of late June, 24 states had passed expansion; 20 had not. Six, including Montana, are still debating the issue, according to the Kaiser Family Foundation.

Expansion opponents in Montana aren’t confident the federal government will be able, in coming years, to maintain Medicaid claim payments, which would then fall to states to cover.

Some say startup costs will tax the state’s budget.

In a, Chronicle guest column earlier this year, state Senate Republican Majority Leader Art Wittich, of Bozeman, said start-up costs are estimated to be about $1 billion “so that the hospital and medical industry can cover their costs of ‘uncompensated care,’” he wrote. “However, a look around the state shows that hospitals continue to add staff, build clinics, expand and pay some of the highest salaries in the state. Saddling taxpayers with yet additional debt to further bloat the medical industrial complex, with no help of cost control, seems unwise.”

Though nobody disputes Medicaid expansion will require more from state coffers, Gregg Davis at the Bureau of Business and Economic Research at the University of Montana estimated the cost to Montana to be much lower and said the economic benefits will help neutralize those costs.

State spending for Medicaid expansion would amount to an additional $194 million, a 3.8 percent increase, according to a study by the Urban Institute, Davis said in a presentation posted on the website of Montana Commissioner of Securities and Insurance Monica Lindeen.

“But the buck doesn’t stop at cost only,” Davis notes. “Federal dollars stimulate economy, leading to increased jobs, labor income, business sales and tax revenues.”

For every $1 billion in federal funds, 18,600 jobs are created, labor income increases $690.3 million and business sales increase $1.5 billion. All that drives state and local tax revenues up $72 million, Davis claims.

The bills for uncompensated care are passed on to paying consumers and insurance providers, who in turn raise their premiums. So if more uninsured people got insurance, there would be less cost-shifting to insured patients.

That’s the premise of the Affordable Care Act, said Mike Fierberg, public affairs specialist with the Centers for Medicare and Medicaid Services in Denver.

“The law presumed all those people would go on Medicaid,” he said. “Nobody expected the Supreme Court to rule the way they did.”

Davis estimates that hospitals, community care providers and physicians combined provided $268.3 million in uncompensated care in 2011 in Montana. Uncompensated care would decrease by $56 million under expanded Medicaid, he figured.

The net cost of Medicaid expansion to Montana taxpayers, Davis surmised, is about $138 million.

Not passing Medicaid expansion “was one of the glaring failures of this Legislature,” said Kevin O’Brien, spokesman for Gov. Steve Bullock, on Friday.

“When you take the politics out of it, assuring low-income families have access to affordable health care is good for the economic benefit of the state,” he said.

But there’s still a chance it could happen.

During the legislative session, the Senate passed the proposal, but it was held up in a House committee. An efforts to blast the bill out of committee to the House floor received 55 votes – not the 60 needed.

However, O’Brien noted, there was a clear majority in favor of the move, and he said, had the proposal made it to the floor, it would have passed.

Though he declined to say if Bullock will call a special session of the Legislature to take up the issue again, O’Brien said the governor is looking at all options.

“We will expand Medicaid. We will create jobs. We will ensure that we provide affordable care to low-income Montanans, with or without the Legislature,” O’Brien said. “If we don’t do this, Montana taxpayers’ dollars are being sent to cover people in New Jersey and California.”

And that’s one thing that really irritates health care advocates.

“I’m annoyed as an individual taxpayer because I pay federal taxes,” Cooney said. Federal tax money that was appropriated for Medicaid expansion “is not getting returned to us in Montana. I’m surprised Montana taxpayers aren’t more enraged.”

Meanwhile others are drafting ballot initiatives.

Kim Abbott, co-director of the Montana Human Rights Network, said her group is drafting ballot language to be submitted within the next few months.

But the initiative, if it gets support, would not be on the ballot until November 2014, leaving the state to miss out on the first year, when the federal government promises 100 percent claim payments.

“What’s best for Montana is if the Legislature comes back and gets this passed right away,” Abbott said.

As for Gambrel, his back issue will likely be resolved in about a month, and he’ll return work and be able to afford insurance. Still, he believes Medicaid should be expanded.

“Whether or not this helps my family, I still support it,” he said. “Because nobody should have to go through this.”

Jodi Hausen can be reached at or 582-2630. Follow her on Twitter @JodiHausen or on Facebook at Jodi Hausen, journalist.