Montana Medicaid: Repeal or expansion? Both carry costs
(UM Community News Service) Mykal and Julie Funk underestimated the cost of housing when they moved to Missoula three years ago and spent six months living in their car.
Julie, 38, was born with spina bifida. She is paralyzed and uses a wheelchair. Her partner of 17 years is 38-year-old Mykal, who has Asperger’s syndrome and suffers from back pain and other ailments.
Medicaid, the state-federal partnership that helps some of Montana’s poor with health care costs, has always covered Julie. But Mykal wasn’t able to get coverage for himself until the 2105 Legislature expanded Medicaid.
Before qualifying, Mykal used the emergency room for treatment of his gastroesophageal reflux disease. The condition could be treated at a less expensive clinic, but not without insurance. Mykal said he knew it was an inappropriate use of the ER.
“I had to count on the hospital to swallow the bill,” Mykal said.
Through expansion, Mykal has been received treatment for his back pain and gets preventative care. He is enrolled in an online service, Career Step, and will complete training for work in medical billing or coding in February.
“It’s exciting and it’s scary,” Mykal said.
It’s scary because the increased income may cost the couple benefits and services. Mykal wants to work, but he’s not guaranteed a living wage. The eligibility requirements are disincentives for Mykal to make more money because he’ll lose subsidized health care services, but won’t be able to cover them himself.
Health care or work?
This was a common worry for a group of 13 people who gathered recently at Missoula’s Partnership Health Center for a meeting of the center’s Patient Council. Director Laurie Francis led the meeting at the center, where 43 percent of its 16,000 patients live at or below the federal poverty level.
“We treat the ramifications of poverty all day long,” Francis said.
Since Medicaid expansion, the center’s number of uninsured patients has dropped from over 50 percent to 20 percent, she added.
That not surprising. Statewide enrollment in Montana’s Medicaid expansion program has surpassed what lawmakers predicted when the bill was enacted in 2015. Expanding it beyond 2019 would mean higher costs to the state, though the federal government provides most of the money.
In the run-up to the 2019 legislative session, legislators are already talking about possible changes to Medicaid, with solutions ranging from repealing expansion to restricting enrollment and other ways to cut costs.
For Senate Minority Leader Jon Sesso, D-Butte, passing expansion was a giant step forward for Montana. He said the rising health care costs need addressing, but providing access to through government programs is the right thing to do.
“It’s who we are, taking care of each other,” Sesso said.
Since 2015, the federal government has paid for 100 percent of Montana’s Medicaid expansion. If the Legislature extends it, the feds would pay for 90 percent, leaving state lawmakers to determine where the additional 10 percent will come from.
This November Initiative 185 pitched that question to voters, who rejected it by over 27,000 votes. The measure would have paid for expansion by increasing taxes on tobacco products.
Bullock’s plan and opposition
In his budget proposal, Democratic Gov. Steve Bullock is requesting new taxes on things like hotel rooms, rental cars and liquor to pay for Medicaid expansion. Legislative fiscal analysts estimate it would cost the state $59 million to continue Medicaid expansion over the next two budget years.
But Senate President Scott Sales, R-Bozeman, said Bullock’s tax increases are a non-starter for him. He said he’s not inclined to vote for expansion because Montanans cannot afford the program in the long run.
“I think (Bullock’s proposal) is a little tone-deaf, especially after the defeat of I-185,” Sales said.
That’s the same stance Sales took in 2015, as did many Republicans who voted against expansion. Sales said costs remain a big concern. Another, he added, is a lack of work requirements for those who are able.
Heading in the legislative debate, the politics on Medicaid expansion aren’t entirely polarized. Medicaid expansion passed in 2015 when a faction of Republicans joined Democrats, and that’s a possible scenario for the 2019 session too.
Ed Buttrey, a Great Falls Republican, carried the bill four years ago when he was in the Senate. Now in the House, Rep. Buttrey plans to carry it again. He said he’s confident expansion can pass – with some tweaks.
Buttrey plans to release a draft of the Medicaid Reform and Integrity Act in January. It will likely include requirements that some recipients work or perform some kind of community service. Buttrey said there will be exceptions but added that everyone should have “some skin in the game.”
“It has to be a Montana-flavored solution,” Buttrey said.
Democratic leaders like Sesso are supportive, though he was reluctant to predict how the state would pay for it.
Meanwhile, Mykal and Julie Funk anxiously await the outcome. Julie will be able to stay on Medicaid no matter what, but Mykal’s health care future is uncertain.
“If Medicaid (expansion) fails, I won’t get coverage,” he said.
This story was written for the University of Montana’s Community News Service, which features coverage from students at UM’s School of Journalism. Editors with questions about this story may contact reporter Shaylee Ragar (firstname.lastname@example.org) or supervisor Dennis Swibold (email@example.com).