HELENA — When Montana lawmakers approved renewing the state’s Medicaid expansion in 2019, it came with a clear deadline: Leaders would have to decide by 2025 whether they wanted to keep the program going. Now that date is fast approaching, and the state Legislature will decide the way forward during their upcoming session.
“We've created a program that's working extremely well and has been a huge benefit for Montanans, especially in the mental health and addiction areas, and to lose that would be catastrophic for the state,” said Rep. Ed Buttrey, R-Great Falls.
Buttrey sponsored the HELP Act that established Medicaid expansion in 2015, as well as the 2019 bill that extended it through 2025. In both cases, the majority Republicans in the Legislature split; a group of Republicans and Democrats sent the bills forward to Democratic Gov. Steve Bullock’s desk.
Buttrey says he saw Medicaid expansion as a way to advance both health care and economic goals – getting Montanans healthier and keeping more of them in the workforce. He believes it’s been a success, and he plans to bring a bill during the session that would simply remove the June 30, 2025 sunset date.
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“Now we've got ten years’ worth of data, and that data is positive from the state's perspective, from the budget perspective, from the hospitals both large and small – we’ve had no closure of rural hospitals, one of the few states that can say that – and certainly has been a huge benefit for people on the program,” he said.
Democrats in the Legislature have also talked about making Medicaid expansion a priority, but Republicans still hold majority control in the House and Senate – and they now have the governor’s office as well. Not all GOP members are enthusiastic about extending the program.
“I campaigned this time – I had a primary as well as a general – and promised my voters that I'm against Medicaid expansion,” said Sen.-elect Matt Regier, R-Kalispell. “I get everybody's district is different, but that's something that the people there in Senate District 5 voted down, and I'm going to uphold that.”
Regier, the incoming Senate president, voted against extending Medicaid expansion in 2019, while serving in the House. He called the program “welfare,” argued it’s benefited hospitals – particularly large hospitals – more than individuals, and said people now on the program have other options for insurance.
“I'm all for a safety net,” Regier said. “The question that we're going to have to answer is, when does a safety net become just a lifestyle and not a safety net anymore?”
Buttrey argued the results of the program have shown answers to concerns opponents raised.
“We heard a lot of things: We heard it would bankrupt the state, we heard that once folks get on the program, they'll never get off,” he said. “Like I said, we now have ten years’ worth of data that shows the exact opposite to be true. It's been a net positive for our state budget and taxpayers. People are going off of the program once they get the help they need.”
A report from the Montana Healthcare Foundation says the population enrolled in Medicaid expansion has fluctuated – rising to near 100,000 in 2018 before starting to decline, then rising again during the COVID-19 pandemic. It hit its highest point – 125,035 adults enrolled – in April 2023, as the federal government allowed people to remain on the program without rechecking their eligibility.
When the federal COVID public health emergency ended in April 2023, states had to resume redetermining Medicaid recipients’ eligibility. In Montana, the number of people on Medicaid expansion fell consistently from that point, reaching 77,398 by September 2024.
Lawmakers won’t only be deciding whether to continue Medicaid expansion during the upcoming session; they’ll also debate whether to make changes to the program.
When unveiling his 2025 budget proposal last month, Gov. Greg Gianforte told reporters it would include funding for renewing Medicaid expansion, though he said he wanted to work with the Legislature to add work requirements to the program. Regier also said, if there are enough votes to continue the expansion, he hopes lawmakers will look at changing some of the details, like work requirements.
The 2019 renewal did add what are called “community engagement” requirements for people on Medicaid expansion – requiring them to spend 80 hours a month on work, education, workforce training, volunteering or other approved activities to receive benefits. However, they never went into effect because the state needed to receive a waiver from the federal government before implementing them.
Buttrey said he believed the transition from the Biden administration to the Trump administration could change the situation.
“My hope is that under a new administration federally, that we would have the opportunity to once again apply for these waivers,” he said.
Rep. SJ Howell, D-Missoula, told reporters last month that Democrats believe the debates over details like work requirements were already settled, and the program is effective as it is. They said they’re open to discussions about models other states are using, but the priority is maintaining what Montana already has.
“I think that we've got a lot of data that shows Montana's Medicaid program is working, and a lot of data that shows some of these other programs are not,” said Howell.
Democrats have talked about wanting to make some changes to Medicaid expansion – including returning to 12-month continuous eligibility, which allowed those on the program to keep coverage for a full year even if their income rose to a level where they’d otherwise be ineligible. The Legislature ended funding for that policy in 2021.
Changes at the federal level are also creating some uncertainty about funding for Medicaid expansion. Currently, the federal government reimburses Montana for 90% of the costs for providing services to people on Medicaid expansion, leaving the state to pay the remaining 10%. For those on traditional Medicaid, the federal share is closer to 70%. Advocates for the program have pointed to that as a financial benefit for the state, if people who would otherwise be covered by traditional Medicaid are instead on Medicaid expansion.
Regier said, with a Republican administration taking over at the federal level, it’s possible that formula will change.
“A logical first step would be for the federal government, if they're going to try to balance their budget to come first to the states and say, ‘Okay, we're going to start pulling back,’” he said. Right now, Medicaid expansion is a nine-to-one match – that’s huge, that’s $900 million from the federal government. I could see them starting to ratchet that back, which puts more on the state. So that is a risk if we continue this program and continue to rely on the federal government.”
Buttrey said the law already includes triggers that would require the Legislature to come back and reconsider the issue if the funding formula changes, so he doesn’t believe that’s a reason not to move forward.
“We've looked at every other state’s programs, both Medicaid expansion and more traditional Medicaid programs, and we found ours to be the most efficient, to be the most cost-effective and provide the best service,” he said. “But I'm always willing to listen. If folks have other ideas and we can get it through the federal agencies, then I'm always willing to listen.”
When the Legislature begins its session on Jan. 6, it will be just under six months to go before the June 30 sunset date.
NOTE: This is the second of a two-part story taking a closer look at the issue of Medicaid expansion, ahead of the start of the 2025 Montana legislative session. On Thursday, MTN had more on who’s getting coverage through the program and the impacts one rural hospital has seen since expansion took effect.
