GOP-Held Senate Approves Medicaid Expansion on Initial Vote

A Republican-sponsored bill to continue Medicaid expansion cleared a key vote in the Montana Senate on Thursday, February 20.

House Bill 245, sponsored by Rep. Ed Buttrey, R-Great Falls, passed an initial vote by a 29-21 margin. The bipartisan coalition supporting the bill was nearly identical to the group of 18 Democrats and nine Republicans who have recently succeeded in undermining Senate GOP leadership.

Supporters of the bill said Thursday that the program had become a lifeline for people who don't have health care coverage through their employer or the federal marketplace, with some lawmakers sharing how the program has helped their parents and children.

Other supporters testified that Medicaid expansion helps keep small businesses in the black and allows health care providers to keep their doors open, especially in rural areas, by reducing how much they spend caring for uninsured people.

"For those of you who represent Montana's most rural communities, ask yourself this: Where will your constituents go if their father has a heart attack? When their child is in a car accident? Or when your wife goes into labor?" said Sen. Gayle Lammers, R-Hardin, who carried the bill on the Senate floor. "Because without Medicaid expansion, many of those health care providers may not be there when you need them."

The program has been in place since 2015. As of November, it covered about 76,000 Montanans with annual incomes up to 138% of the federal poverty level, or about $15,650 for an individual.

HB 245 is the Legislature's primary vehicle for reauthorizing Montana's health care coverage program for low-income adults between the ages of 18 and 65. A similar but more expansive bill backed by Democrats failed to pass out of its first committee in January.

The bill that's nearing the governor's desk includes community engagement requirements, commonly referred to as work requirements. The Legislature first enacted those measures in 2019 but they have not yet gone into effect because of Biden-era federal restrictions. The administration of President Donald Trump has signalled that it is open to accepting state requests for Medicaid work requirements.

HB 245 also lifts the recurring sunset provision that has required the program to be repeatedly reauthorized by the Legislature. Buttrey has said that lawmakers will still have the power to end or adjust the program in future sessions, even without the sunset cliff.

Montana's Medicaid expansion program has a roughly $1 billion annual price tag, 90% of which is covered by the federal government. That federal cost share agreement is more beneficial for state coffers than that for other Medicaid programs, leaving Montana on the hook for about 10% of program costs. Montana uses a mix of state General Fund and other special revenue sources to cover its share.

But Medicaid expansion has faced consistent headwinds from fiscal conservatives in the Legislature. Some have advocated for stronger work requirements for beneficiaries while others forecast that it will become unsustainable if the federal government reduces its share of the cost. Others decried any type of public health coverage as "socialized medicine," and said that people should not rely on a social welfare system at all.

Some of those concerns were also raised by House lawmakers during debate over Buttrey's proposal in early February. But that Republican-majority chamber also ended up supporting the measure by a roughly 25-vote margin.

Sen. Carl Glimm, R-Kila, said during the Senate's Thursday debate that the evolving federal landscape under Trump and a Republican-controlled Congress raises the real possibility of Montana being stuck with a larger bill.

"This is extremely low fruit. They give us $900 million to run this program every year," Glimm said. If the federal share changes, he continued, the Legislature will likely have to reconvene for a special session.

"And I'm going to tell you, 'I told you so,'" he said.

Other lawmakers voiced their own concern about the federal debt and the possibility that some Medicaid enrollees take advantage of the program. But some, including Sen. Jason Ellsworth, R-Hamilton, also said that the program helps people who fall into an economic gray area - those who are working but don't have enough income to afford other forms of insurance. Having voted against Medicaid expansion in 2019, Ellsworth said he supports the program this time.

With the solidified backing of Democrats and a portion of the Republican caucus, GOP leaders in the Senate noted that Medicaid expansion opponents were facing a losing battle this session.

Sen. Dennis Lenz, R-Billings, spoke about his and Senate Majority Leader Tom McGillvray's calculation to help the bill advance Monday out of a Senate health committee in an attempt to move past further contentious debates within the fractious chamber. But Lenz said he wished that lawmakers had the political leverage this session to make Medicaid expansion a better program that clearly improves health outcomes for beneficiaries.

"We lost the squeeze on this. We lost the ability for a better Medicaid, a better Medicaid system, a better approach to how we do things here," Lenz said during debate Thursday.

Senate President Matt Regier, R-Kalispell, expressed a similar resignation near the end of Thursday's session. He said the vote was likely set in stone, but still encouraged his colleagues to think about the overall cost to taxpayers created by expansion and other Medicaid programs.

"We all have different constituents. I made campaign promises. You guys did too. Vote that way," Regier said. "But I think beyond this, we need to, as Montana and Montana state government, we need to have a conversation of, what is the role of state government? What programs are beneficial mostly for the people of Montana?"

At the end of the Thursday floor session, McGillvray moved to refer the bill to Senate Finance and Claims, the chamber's primary budget committee, without a vote or objection.