Montana Public Radio is bringing you election coverage this year that focuses on the issues voters say are a priority for them. Health care is one of those — from abortion access to getting timely care, health care reporter Aaron Bolton spoke with MTPR's Elinor Smith about the context behind some voters' concerns.
Elinor Smith: Hey Aaron.
Aaron Bolton: Hey Elinor.
Elinor Smith: We’re going to get to as many health care topics as we can over the next few minutes. There’s already been a lot of reporting done on the fight over abortion access in the state Constitution, so we’ll spend our time elsewhere now. Aaron, what else have you been hearing from voters when it comes to health care?
Aaron Bolton: I want to start out with the big bucket of Medicaid programs.
Elinor Smith: Ok, can you remind us what Medicaid is.
Aaron Bolton: Medicaid is the health care coverage program for low-income people. It provides health care to 20 percent of adults and nearly 40 percent of children in the state. Part of that coverage includes mental and behavioral health care.
Our fellow MTPR reporter Shaylee Ragar spoke with Aimee Still of Great Falls this summer. Still relies on Medicaid so her kids can get behavioral health treatment through a special program at school.
Aimee Still: “I’m not Democrat and I’m not Republican. I vote on what I believe in … These kids didn’t choose these lives. They don’t get to vote to decide their futures. It’s up to us to help them to have better lives than we had.”
Elinor Smith: Ok, so a lot of Montanans use this to get care. Any changes to the program at stake this election year?
Aaron Bolton: State lawmakers elected this year will vote early in 2025 on whether to renew Medicaid expansion.
This expansion was brought about through the Affordable Care Act under the Obama Administration. In short, it provides Medicaid coverage to people above the poverty line. They don’t qualify for traditional Medicaid, but they also can’t afford private insurance. It’s there to fill an insurance coverage gap.
Nearly 100,000 Montana adults and children are on the program.
Elinor Smith: What happens if Montana’s Medicaid expansion goes away?
Aaron Bolton: Montana’s uninsured rate could go up. When Montana became an expansion state about 10 years ago, the rate of uninsured Montanans was cut in half. That rate has hovered at about 8% ever since.
The Montana Health Care Foundation estimates that the money hospitals lost from uninsured patients declined 59% because of Medicaid Expansion. That’s more than $15 million. The program is lauded as the main reason we haven’t seen small hospitals close like in non-expansion states.
The federal government also picks up 90% of the tab for many programs under Medicaid expansion. That’s compared to the feds paying for two-thirds of the cost when Montana wasn’t an expansion state.
Elinor Smith: What are the chances lawmakers and the governor renew the program next year?
Aaron Bolton: Gov. Greg Gianforte says he generally supports Medicaid expansion, and suggested he may also support work requirements for people enrolled in the program.
Democratic challenger Ryan Busse says he fully supports Medicaid expansion.
Elinor Smith: But lawmakers would have to first approve the program’s renewal. What do we know about the chances in the Legislature?
Aaron Bolton: I wish I had my crystal ball to give you an answer, but we just don’t know. But I can tell you lawmakers renewed the program back in 2019 after a lot of fights over work requirements, which were passed but not implemented. That could certainly be a fight again, especially if Trump wins the White House. That’s because the federal government has the authority to approve that. But the vote last time was tight, passing with only a one-vote margin in the Senate . That’s because some Republicans think the program is too expensive and say the private sector should fill this gap.
Elinor Smith: So coming out of the weeds of Medicaid Expansion, what else are voters talking about?
Aaron Bolton: Indigenous voters told MTPR that they struggle to access care through the Indian Health Service. That’s the federal health system for Native Americans. Dawn Blatt of Rocky Boy says she’s been trying to get a referral for her mom.
Dawn Blatt: “I’m … waiting for a referral to get out and see a neurologist because she’s got something like a tumor growing in her head.”
Elinor Smith: Funding for IHS was brought up in the recent U.S. Senate debate between incumbent Democrat Jon Tester and Republican Tim Sheehy. Both candidates agreed the agency was underfunded, but how bad is it?
Aaron Bolton: Congress gave the agency $7 billion this current fiscal year. A congressional workgroup made up of tribes estimates the agency needs seven times that amount to meet current patient needs.
Elinor Smith Wow, so is that why people like Blatt are waiting to get things like referrals for care? The agency just can’t afford to pay for that?
Aaron Bolton: Yeah. IHS has a specific pool of money for community care. It’s said it will make referrals if it has the funding to pay for it. But a lot of times, it doesn’t.
Sara Rosenbaum is a health policy expert at George Washington University. She says to make matters worse, the uninsured rate for Indigenous people is high.
Sara Rosenbaum: “People are not insured, so people really depend on the IHS to finance the care they need.”
Aaron Bolton: For uninsured Native Americans, that means they don’t get the care if IHS doesn’t have the money to pay for it.
Elinor Smith: Going back to the Tester-Sheehy debate, what did we hear on IHS funding?
Aaron Bolton: I think it’s worth pointing out that funding for IHS hasn’t been a big campaign topic and the debate is really the only time we’ve heard any congressional candidates extensively weigh in on it.
Here’s Tester responding to a question about what the federal government can do to increase life expectancy for Indigenous Montanans, which is the lowest among all racial groups.
Jon Tester: “And you can take a look at the money that’s spent in Indian Country for health care, and it’s a pittance compared to what’s spent in the private sector.”
Aaron Bolton: He says more funding needs to go to the IHS to meet patient needs. And Sheehy said he agreed.
Elinor Smith: We also heard a lot of talk about other federal health programs during the debate, specifically care for veterans. Montana has some of the most vets per capita of any state in the country. What did both candidates say?
Aaron Bolton: Sheehy said as a veteran himself that he would prioritize those issues in the Senate. But he hasn’t put forth specifics. He continued to say the VA is a broken system.
Tim Sheehy: “Building more VA clinics isn’t the answer. Building more VA clinics we can’t fill isn’t the answer.”
Aaron Bolton: He did say private health care programs can do a better job taking care of veterans and wants vets to have more community care options. But he didn’t say he wanted to completely privatize that system or other federal health care programs like Medicare.
Tester is the chairman of the Senate Veterans Affairs Committee. He said the VA isn’t perfect but it's come a long way and he’s worked to improve it.
Elinor Smith: What other health care issues are you hearing about from voters?
Aaron Bolton: I recently talked to a voter in Missoula at a Tester campaign event about Medicare. Joyce Westerbur says Medicare Advantage is an example of a private federal health care program that isn’t working.
For those who don’t know, Medicare Advantage are insurance plans run by private companies that seniors can choose over traditional Medicare.
About 77,000 Montanans are enrolled in those plans, according to KFF, a nonpartisan health policy research group.
That’s about 30% of Montana’s Medicare-eligible population. That’s actually a lot lower compared to many states, but the private insurers are quickly growing enrollment rates in rural states, quadrupling since 2010.
That’s because they offer cheap or zero-dollar premiums, which is enticing for healthy seniors. But Westerbur says the private companies contracted by Medicare put up barriers to care.
Joyce Westerbur: “The problem is there’s all these pre-authorizations that are required before you get the care you need. ”
Aaron Bolton: People like Westerbur say profit motives need to stay out of federal health care programs.
Elinor Smith: I’m sure there are other health care issues on the mind of voters, but that’s all we have time for today. Aaron, thanks for talking this over.
Aaron Bolton: Thanks for having me.
