Medicaid Expansion Bill Fails to Gain Support in Montana Legislature

The sponsor of an ambitious Democratic effort to overhaul Medicaid expansion offered to gut her own bill Tuesday just four weeks into the legislative session. But it was not enough to garner support from Republicans on the committee, who voted against what would have been a much leaner version of the proposal.

As originally written, House Bill 230 from Rep. Mary Caferro, D-Helena, would have nixed work requirements, reopened in-person public assistance offices and made it easier for people to sign up for Medicaid and stay enrolled.

Despite its lofty goals and a Republican-majority Legislature, Caferro said at a press event earlier this month, "Our bill is smart, and I'm sticking to it."

At the House health committee on Tuesday, Caferro brought an amendment that slashed almost all of those provisions from the bill. Other than the reauthorization of Medicaid expansion, all that remained in the updated version was a $3 million allocation to reopen 10 public assistance offices and direction to the state health department to improve its communication with enrollees.

Even so, all 12 Republicans on the committee voted against Caferro's amendment and then the bill as a whole. HB 230 was tabled in committee and will not move forward.

Medicaid expansion provides government-funded health insurance to low-income households earning below 138% of the federal poverty line -- about $20,782 for a single individual. Roughly 77,000 Montanans receive coverage through the program. Nearly a decade since Medicaid expansion was first enacted, the Legislature must take action this session in order to reauthorize the program before it sunsets in June.

Rep. SJ Howell, D-Missoula, said paring back the proposal demonstrated a commitment on the part of supporters to reauthorizing expansion while focusing on changes that would help everyday people, dozens of whom testified in an hours-long hearing last week.

"I think we all share a commitment to good customer service, to the state doing well by Montanans," Howell said.

That said, there appeared to be some energy among Democrats and even a couple Republicans to pull out some of the elements of Caferro's bill and propose them as standalones.

"I really like some of this customer service provision here, and look forward to supporting that separate from some of this other stuff," said Rep. Nelly Nicol, R-Billings. "So, unfortunately, I am going to have to be a 'no,' but I really hope that some of this comes forward."

A separate bill from Rep. Ed Buttrey, a moderate Republican from Great Falls, faced a different fate. House Bill 245 would reauthorize the Medicaid expansion program as it currently stands, but simply repeal the sunset.

The committee voted 14-7 to advance HB 245 to the House floor, with Democrats joining moderate Republicans, demonstrating some bipartisan support of the more measured take on expansion reauthorization. Seven more-conservative Republicans opposed the bill.

Montana's existing Medicaid program, crafted in its current form in 2019, requires people to demonstrate employment or participation in workforce training, education or other "community engagement activities" for at least 80 hours each month to be eligible.

But the federal government -- which must approve changes to every state's Medicaid program -- under then-President Joe Biden denied the work requirement provision. Under President Donald Trump, the Centers for Medicare and Medicaid Services is expected to embrace work requirements and other state efforts that could restrict Medicaid enrollment.

Buttrey's HB 245 maintains those employment requirements alongside a workforce training program at a small cost to the state.

Two additional proposals pertaining to the future of Medicaid expansion are also in play. Conservative Republican Senators Carl Glimm and Jeremy Trebas are selling far more limited versions of the program. Both preach self-sufficiency and caution against overreliance on government support.

Glimm, a member of the Montana Freedom Caucus from Kila, sponsored Senate Bill 62, which would phase out expansion by prohibiting any new enrollees after Sept. 1. He called the concept a "soft unwind" rather than a "hard stop."

"Let's get Montanans back to work," Glimm said at a Jan. 13 press conference, in which the caucus stated that halting Medicaid expansion was a top priority.

When asked about the appetite among his colleagues for phasing out expansion, Glimm said, "We'll see when we vote, won't we?"

SB 62 passed its first test last week. While nobody testified in favor of the bill at the Jan. 22 Senate health committee hearing, it advanced 6-5 through the GOP-led committee with no discussion from lawmakers.

Sen. Mike Yakawich, R-Billings, was the lone Republican to vote against it.

Senate Bill 199 from Trebas, R-Great Falls, would cull the list of activities that make a person eligible for health coverage under Medicaid expansion's work requirement. It would eliminate substance use education and volunteering as permissible activities, and people living in high-poverty areas or experiencing chronic homelessness would no longer be eligible for those reasons alone.

Relative to the other three Medicaid proposals currently being considered by lawmakers, Trebas said his proposal was a "middle option" because it keeps expansion but tightens the parameters for eligibility.

Critics had another name for it: "A poison pill."

At the Jan. 27 Senate health committee hearing, opponents said the bill includes language to trigger the sunset of Medicaid expansion if the federal government doesn't approve the work requirement. They said it introduced uncertainty into a lifeline for already-vulnerable people. It also had zero proponents at its initial hearing.

"If (this) is a poison pill, then (the HELP Act) was a bait-and-switch," Trebas said, referencing the 2019 Medicaid expansion renewal bill that included work requirements.

Senate health committee members will vote on whether to advance the bill soon.

Carly Graf is the State Bureau health care reporter for Lee Montana.