“There’s too much at stake to not keep Medicaid expansion going in Montana,” Bullock says.
Montana’s Medicaid expansion provides health coverage to just over 96,000 people, and it’s set to expire next June.
Expansion narrowly became law in Montana over three years ago. It extended government-funded health coverage to people with incomes below about $16,000 a year.
The future fate of the local law born from the federal Affordable Care Act, also known as Obamacare, is set to define much of the legislative session beginning in January.
On Thursday, Bullock said continuing expanded Medicaid is not only important for the people it now covers, but also for the state’s hospitals that now give away less care for free.
“It threw a lifeline to our rural communities. Rural hospitals in states that did not expand Medicaid have been closing six-times faster than those that did. In Montana, since we expanded Medicaid we haven't lost one hospital in our entire state.”
As Bullock laid out budget goals for the state over the next two years he portrayed the future of Medicaid expansion as a settled matter - that it will continue but perhaps look different following the legislative session.
That’s not how some Republican leaders see it.
“I don't think it's a foregone conclusion to say that Medicaid expansion is going to pass in any certain form - or pass at all. I think that that is still up for debate,” said Senate President Scott Sales.
Sales says if lawmakers choose to continue the health care program there will likely be additional requirements for recipients, like restricting eligibility for people with significant assets, even if they are low income, work requirements, and possible drug testing.
Much like when Medicaid expansion passed in 2015, its continuation, and possible new form, could come down to how moderate Republicans in the legislature work with Democrats and Governor Bullock.
Sales says he sees the brewing fight broken up into three political groups operating within the state capitol.
First, there’s the Democrats, including Governor Steve Bullock.
“The Democrats that think that abled bodied people have a fundamental human right to health care, without any strings attached," Sales says.
Then there’s the significant portion of the Republican legislature that has always opposed Medicaid expansion.
“And obviously we have members of our caucus that are somewhere in between,” Sales says.
These are the moderates that helped pass Medicaid expansion with Democrats, known as the HELP Act, in the first place.
In the background political horse trading is what the failure of state ballot initiative 185 last week means. It would have re-authorized Medicaid expansion and used a tax on tobacco products, e-cigarettes and vapes to help pay for it.
Republican leaders and Governor Bullock aren’t seeing eye-to-eye on what voters intended when they rejected I-185.
Bullock says the tobacco industry bought themselves a victory when it spent a record amount in the state opposing the ballot initiative.
“I don’t look at it as a mandate of saying that either tobacco shouldn't pay their fair share when it comes to health care, or that anybody wants to roll back the gains that we’ve made in our state as a result of working together through the Montana HELP Act.”
“The public just turned down Medicaid expansion and the tax that would have helped pay for it,” says Republican Fred Thomas, the Senate majority leader.
He says the governor is snubbing the public by assuming Medicaid expansion will continue.
“We’re willing to look at that. We’re willing to work on this issue. But no, we’re not just going to go pass Medicaid expansion. The public just turned it down,” Thomas says.
Governor Bullock says he’s willing to discuss Republican demands of workforce requirements for recipients of expanded Medicaid, while pointing out that those kinds of requirements were blocked by a federal judge when put in place in Kentucky.
When Montana expanded Medicaid, the federal government covered 100 percent of its cost. That ramped down to 95 percent last year and will drop to 90 percent in 2020 and future years. That means the state will still reap hundreds of millions of dollars in federal Medicaid payments, but still have to come up with tens of millions of its own.
Bullock is currently balancing his proposed budget, which includes a built-up rainy day fund, with the help of tax increases on tobacco, liquor, rental cars and hotel rooms. Republicans leaders say they’ll likely reject those, but haven’t said they’re 100 percent opposed to any tax increases at this point.
When lawmakers convene in a month and a half they’ll debate not only the continuation of Medicaid expansion in Montana, but also how to pay for it.