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Holding on: The debate over the future of Medicaid expansion in Montana

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In 2016, a longtime Montana senator had a prediction: Medicaid expansion was done.

It had been a month since the nation learned Donald Trump would be president. The president-elect continued his campaign rally cry to unravel the Obama-era health law called the Affordable Care Act.

That law made it possible for Montana to expand Medicaid to connect the state’s working poor to health coverage. The 2015 Montana Legislature did so through the Help Act, which became law without a vote to spare on the pitch people need to be healthy to be independent.

A year into the program, those who voted down the idea still weren’t sold. The nationwide health reform debate wrapped uncertainty around whether Montana’s expansion would last its four-year test.

Sen. Bob Keenan, R-Bigfork, liked that uncertainty. He was against the expansion from its inception and planned to introduce a bill in 2017 to scrap the program early. With Trump elected, Keenan said he didn’t need that plan anymore.

“Why fight your enemies when they’re already standing on a ledge?” he said at the time.

But the expansion survived and, four years in, the debate around its future has changed. There are 95,000 Montanans on the program with coverage set to expire in 99 days unless lawmakers take action. Keenan is now one of the people with a list of ideas of how it should continue.

“Why the epiphany?” Keenan said on a recent afternoon. “I absolutely believe in the value that Medicaid expansion has had to the reservations, tribal members and the community health centers. I think it’s the inevitability of expansion going past the sunset, being reapplied, reworked or continued.”

There are those who still think expansion is a bad idea. However, the dominating argument isn’t whether Montana should keep the law but how it should look. That's more complicated.

Earlier this month, two proposals went before lawmakers for the first expansion hearing of the session. One comes from a Democrat who largely wants to keep the system and its vast accessibility as is. The other comes from the Republican who sponsored Montana’s original expansion. He thinks the next version needs more rules, but some point to studies that say those changes could halve enrollment. 

The House Human Services Committee heard nearly 9 hours of testimony on the two options, some from people who rely on the program and some from people who want it changed. The committee is due to take action on both bills this week, which need to clear the full House by April 1.

The question is whether either will win enough support to hold onto expansion in Montana.

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The shift in the debate is partially rooted in how Montana’s model unfolded, said Jeremy Johnson, a political science professor at Carroll College. More people signed up than expected. The state predicted 45,000 enrollees by 2020, which the program surpassed its first year.

“That makes it more expensive but also more popular,” Johnson said. “So many clinics and hospitals rely on expansion for the people they serve, that happened faster than expected.”

There’s also a change on the national scene. Republicans’ largely symbolic threat to throw out the Affordable Care Act, also known as "Obamacare," became possible with President Trump. Even so, major reform didn’t happen.

“The most viable Republican possibilities, pared down plans with fewer protections, weren’t that popular,” Johnson said. “Since, we’re seeing conservatives moving in that expansion direction. We’ve seen votes in other states, red states, expanding Medicaid.”

Rep. Nancy Ballance, R-Hamilton, was one of expansion’s strongest opponents. She saw the nation’s health policy as one-size-fits all and worked with people in Montana and across the country to find a better option.

Four years later, not much has changed, which Ballance isn’t happy about. But in Montana, she’s watched the expansion’s ripple. Ballance said it filled funding gaps in Indian Health Services and offered people with pent-up needs a path to improve their lives.

During last week’s expansion hearings, Ballance advocated for the policy’s place in Montana through a Republican bill. 

“If we turn our backs on this population, the generational addiction, the child abuse and neglect, the lack of access to care that’s continuous versus just fixing something and just sending someone home ... just goes on," Ballance said. "I can no longer ignore that. I cannot let the Republican ideology stand in the way of what I know is doing the right thing.”

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Hundreds walked into the capitol to give their take on the expansion, forming a long line outside the Old Supreme Court Chambers on March 16.  

When Rep. Mary Caferro, D-Helena, stepped to the podium to introduce House Bill 425, she wore a teal “Medicaid works” shirt. Her bill would increase some of the existing fees and plug more money into the law's voluntary program that helps people find work or a higher paying job.

“I’m here today on behalf of the smallest and the largest voices of Montana," Caferro said.

She stepped back from the microphone and lifted her hands from the packed chamber floor toward the balcony, where many wore the same teal shirt. 

"As you can see, this is an amazing issue we have before us,” Caferro said.

Testimony from expansion supporters included stories from indigenous people with more resources in their communities, people with access to treatment outside of a crisis for the first time and providers with more patients who could afford services.

Her competition is a Republican plan that takes advantage of Trump administration changes, which allowed states to tie more requirements to Medicaid. House Bill 658 calls for enrollees to record 20 hours of work or community engagement a week.

In a pair of black cowboy boots, Rep. Ed Buttrey, R-Great Falls, introduced the Medicaid Reform and Integrity Act. He said the program has been a success but can be better.

“It’s much more than about health care,” he said. “It’s about responsibility and integrity and the ultimate success of anyone who chooses to participate.”

His bill calls on the state to ensure people qualify for the program and sets overall spending caps. It also collects fees from hospitals, insurers and groups that benefit from the expansion.

The cost of the bills, in state spending terms, is pretty much a wash. The Republican plan is estimated to cost roughly $47.2 million from Montana’s general fund over four years. The Democrat’s bill could cost $49.6 million.

Both lawmakers have said increased fees and the feds picking up most of the cost will help the expansion pay for itself. Expansion opponents and even some supporters are skeptical.

The federal government promised to cover 90 percent of state expansion costs. If that match drops, Buttrey said enrollees would either cover the difference, lawmakers would have the chance to act or the law would go away.

Buttrey said some people would receive exemptions from the new rules, like full-time college students and caregivers, or someone living with a substance-use disorder.

Some, like a former state Medicaid director, said Buttrey’s provisions could warrant federal disapproval and risk killing the state’s expansion.

If it does go through, those who don’t want the new rules say it will sever people from care. A state fiscal analysis estimated Buttrey’s changes could cut enrollment in half. 

For lawmakers like Keenan, that’s not a problem. He is in the camp that argues too many people signed up in the first place. In fact, Keenan said Buttrey’s bill doesn’t go far enough to ensure the system weeds out fraud and stays within Montana’s budget.

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A minority of those who testified, including several Republican lawmakers, said any expansion comes at too high a price. There were people who stood in both Caferro and Buttrey’s lines as supporters.

John Harwood struggled with which category to join.

“Expansion needs the discipline and direction of mature parties trying to make it work,” he said. “I don’t think either plan is there yet.”

Harwood describes himself as a Christian conservative Republican. He and his wife owned a farm in rural northern Montana when one of their four kids was diagnosed with autism. Diagnoses like childhood-onset schizophrenia continued to stack up.

By the time their son Craig was 8, he already received psychiatric treatment at Shodair Children's Hospital after his episodes became dangerous. Harwood felt like a spokesperson for services in-state.

“With Craig, starting 30 years ago, we saw the need and experienced the need to have state Medicaid services,” Harwood said.

He said the expansion widened the net of social services too far.

A year after the expansion became law, Montana faced a budget shortfall that initially carved out millions in its health spending. Some of that money returned, but the state lost services and providers along the way — the same services Harwood had advocated for.

“How could they,” Harwood said. “Medicaid was for the destitute. You can’t begin to build services for the next tier of people and continue to do more damage.”

Jason McNees sat in a row across from Harwood and held his typed-out testimony — the ideal example of how Montana’s expansion could work. When the expansion began to unfold, it had been a decade since McNees had insurance. He was 31 and on pre-release in Helena, charged with stealing a car and criminal endangerment.

“Medicaid expansion helped me tackle my opioid addiction and become a resource in the recovery of others,” McNees said.

McNees was raised by his grandparents in Helena. His mom died from an opioid overdose and there was a long history of addiction in his family.

At 22, he worked in restaurants as he studied addiction counseling. One day he bumped his side and the pain never stopped. He was diagnosed with a genetic disorder that causes tumors to grow on nerves.

The surgeries to remove those tumors loaded McNees with bills he couldn’t pay. He was prescribed opiates to treat the pain but never had access to longer-lasting help.

“My life began to revolve around specifically the opioids, not necessarily to manage pain and improve quality of life. They controlled my life more than anything else,” he said.

Roughly nine years into his diagnosis, McNees went to his old doctor for his old meds as an expansion enrollee. When he realized he could access treatment, he never took the pills. He spent two years in recovery through Helena Indian Alliance.

In March 2018, McNees became a peer support specialist for the alliance. He designed and built a support program, which more than a year later has a 76 percent success rate based on retention.

As for the expansion solutions floating around in Helena?

“I’m on the fence about all of it,” McNees said. 

He said Caferro’s bill could buy time to shape the expansion, but he’s worried enrollment and the program’s cost could climb beyond Montana’s capabilities. Like, Harwood, he pointed to other issues in the state that need funding. But he’s worried Buttrey’s bill could go too far to cut people from coverage.

“I understand the big picture, it’s a great program and needs to continue,” McNees said. “I hope it’s an option to better yourself and have a hand up. I hope that it’s cost effective and still able to offer the same quality level of care.”

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Katheryn Houghton can be reached at khoughton@dailychronicle.com or at 582-2628. Follow her on Twitter @K_Hought. 

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