Report Preview: Taxes in Indian Country

Few people understand the nuances of how taxes work in Indian Country. As a result, taxation authority in Indian Country has been one of the most litigated issues between tribes, states, and local governments. Furthermore, there is much misinformation and many missed opportunities for innovative and mutually beneficial inter-governmental collaborations that respect tribal sovereignty.

MBPC is pleased to bring you a series of Policy Basics reports that break down this complex issue. This blog provides an overview of Part 1 and the taxes that individual American Indians in Montana pay. You can get all the details by reading our full report, which will be released early next week. Tribal governments and the taxes they pay and assess will be the focus of Part 2, which will be released later this fall.

Taxes and Individual Tribal Members

According to the U.S. Constitution’s supremacy clause, the Constitution, federal laws, and treaties override conflicting state laws. Additionally, a variety of U.S. Supreme Court rulings have recognized the absolute power of Congress to regulate Indian affairs and property. Altogether, this means that in most instances state and local governments cannot tax tribal members, tribal governments, or their property. However, tribal members living or working off their own reservation are subject to state and local tax laws.

In generally, individual tribal members are subject to federal income taxes. American Indians are also subject to state income taxes if they live or work off the reservation. Regardless of residence, American Indians pay into social security and Medicare, referred to as Federal Insurance Contributions Act, or FICA, taxes.

The U.S. Supreme Court has ruled that tribal members must pay state and local property taxes on their privately owned land held in fee simple status, even if their property is located on their reservation. Likewise, tribal members are also subject to all state motor vehicle taxes if they live off the reservation where they are enrolled. Regardless of residence, all tribal members in Montana must pay vehicle registration fees consisting of vehicle registration, vehicle disposal, weed control, county motor vehicle computer, and where applicable, the gross vehicle weight fees.

Tribal and state governments have each asserted their right to collect excise taxes on reservations, leading to years of costly litigation and tension. As a result, the state of Montana and the seven reservation tribal governments have negotiated a variety of revenue sharing agreements for excise taxes on alcohol, tobacco, and fuel (and in once instance oil and natural gas taxes). The goal of these agreements is to “prevent the possibility of dual taxation by governments while promoting state, local, and tribal economic development.”

Therefore, American Indians in Montana pay excise (or sales) taxes on alcohol, tobacco, and fuel that they purchase. The single exception is members of the Confederated Salish and Kootenai Tribes (CSKT), who do not pay the state tax on cigarettes they purchase on the Flathead Reservation. Because of this, the CSKT government does not receive a remittance share of this particular tax from the state; instead, they receive a limited number of tax-free cigarettes according to quotas set by Montana law. However, any sales above the quota are taxed.

Below is a visual snapshot of the taxes that individual American Indians in Montana pay. The yes-no answers paint a clear picture of what in reality is a complex statutory issue that is still being worked out between governments, Congress, and the courts.

AI taxes

 

 

 

 

 

 

 

 

It is important for policymakers and the broader public to understand how taxes work in Indian Country. This can reduce tensions and help maximize the potential for innovative and mutually beneficial inter-governmental collaborations that respect tribal sovereignty. Check out our blog early next week for Part 1 and stay tuned for more information on taxes and tribal governments, coming this fall in Part 2.

ACA Repeal: What it means for Montana

Today, we released a new comprehensive report on the importance of Medicaid for access to health services for Montana children. Roughly half (51%) of Medicaid enrollees in Montana are children, and any effort to cap and cut Medicaid will most certainly impact access to affordable health care for children in the state.

That said recent press indicates that U.S. Senate Majority Leader Mitch McConnell may pivot to again forcing a vote on a full repeal of the Affordable Care Act (ACA) without a replacement in place. So while we are excited about our new report, we suggest dusting off our report from earlier this year, about what it means for Montana to repeal ACA without a replacement. Analysis shows that roughly 142,000 more Montanans would be uninsured.

Assuming Senator McConnell uses a similar version as the bill that passed in 2015, here are the highlights of the ACA repeal’s impact on Americans’ access to health insurance:

Completely end Montana’s bipartisan Medicaid expansion as of January 1, 2020. Montana’s Medicaid expansion has provided health insurance to nearly 80,000 Montanans. There would be no phase out. There would be no statutory option for states to keep their expansions. And, as Senator Daines has called for in the past, there would be no “place to land” for the tens of thousands of working, low-income Montanans who have received affordable coverage though expansion.

Completely eliminate the ACA’s tax credits and cost sharing subsidies – with no replacement – as of January 1, 2020. As of January 31, 2017, 44,415 Montanans have accessed tax credits and cost sharing subsidies, making health insurance affordable. These folks would be left with no help starting in two years.

Immediately repeal the ACA’s high-income and corporate taxes, cutting taxes for millionaires by over $50,000 per year.

What does this mean for Americans’ access to coverage? Based on CBO’s analysis of the previously proposed repeal bill:

  • Coverage: 18 million people would lose coverage in 2018, 27 million would lose coverage by the early 2020s, and 32 million would lose coverage by 2026. These losses reflect both elimination of Medicaid expansion and the virtual collapse of the individual market, as outlined below.
  • Individual market premiums: Compared to current law, premiums would be 20-25 percent higher in the first year, 50 percent higher by the early 2020s, and would double by 2026.
  • Individual market stability: By the early 2020s, about half of the U.S. population would live in areas with no individual market insurers, rising to 75 percent by 2026. Essentially, the individual market would collapse throughout most of the country.

Senate tweaks bill, but it still spells disaster for Montanans

Yesterday, Senate GOP leaders released a discussion draft making some changes to its bill to repeal and replace the Affordable Care Act.

The big picture: none of these changes alters the overall impact of this bill on Montana. It will leave tens of thousands of Montanans without insurance, increase insurance for many more Montanans, and shift billions of dollars in costs to the state that will likely lead to deep cuts to Medicaid coverage.

Leader Mitch McConnell has indicated that the Senate will take a critical vote early next week to proceed to this bill. Here is a quick recap of some of the changes proposed to the Better Care Reconciliation Act (BCRA):

The bill makes no significant changes to the devastating cuts to Medicaid. Previous analysis that Montana would face the loss of roughly $5 billion in federal Medicaid funds likely still holds true. While the bill adds some smaller changes to the Medicaid provisions, many of the minor “fixes” are temporary and are no substitute for actual health insurance coverage. By 2036, Congress will have cut more than a third of Medicaid funds, leaving states to figure out how to provide coverage to the most vulnerable Americans, like low-income children, seniors, and people with disabilities, with significantly fewer federal dollars to do so.

Funding for opioid treatment is a drop in the bucket compared to what Medicaid coverage and Medicaid expansion is doing. The bill adds $45 billion for states to provide opioid use treatment, but this pales in comparison to what Medicaid is already doing and can continue to do for substance use disorder (SUD) treatment. Medicaid is the single largest payor for SUD treatment. Eliminating Medicaid expansion will result in tens of thousands of Montanans losing coverage, many of whom are getting preventative care, mental health treatment, and SUD treatment that they have never received before. It’s like pulling a patient out of the ICU and handing them a Band-Aid. 

Added funds for home and community-based services creates a false sense of security for states that will face growing health care costs and a growing aging population. The bill provides states with additional federal matching funds for increased payments to providers for home and community-based services (HCBS) for aging Americans, but these funds are temporary and cannot be used to expand services to additional individuals. With the deep cuts in federal Medicaid funds, it’s unclear how helpful this will be if/when the state has to cut current HCBS to cover other mandatory Medicaid costs.

The change to move costs associated with public health emergencies outside of the Medicaid per capita cap is narrow and insufficient. This change would allow states to apply to ask the feds to exempt costs associated with a public health emergency from the per capita cap amount, but it is not at all certain how this would work. The feds could deny an application, and even if it is approved, the amount is capped and would not factor in other increased health care costs within Medicaid (ex., new technology or new drugs).

The “Cruz amendment” makes this bill even worse, and sicker and older Montanans won’t be able afford insurance. The bill would allow a state to offer pared-down plans, as long as the state provides one insurance plan that complies with current Affordable Care Act requirements. This has the effect of bifurcating our insured population into two: those who are older or sicker, who need comprehensive coverage, and those who are younger or healthier (at least healthy right now), who will choose less comprehensive coverage. By siphoning off younger individuals, those who are older or sicker and need good insurance will be forced into a plan that is very expensive (and in many cases, unaffordable). This will be particularly the case for middle-income families who are also losing access to tax credits under this bill.

Now is the time to make your voices heard. The Senate needs to scrap this bill, start over, and work in a bipartisan manner to make health insurance more affordable and stabilize the health insurance marketplace.

Senator Daines continues to misconstrue the impact of Senate GOP health plan

On Wednesday night, Senator Daines held a tele-townhall to discuss the Senate GOP plan with Montanans. There are several instances where his statements don’t necessarily match up with the facts of the Senate GOP plan or its impact on Montana. We know from the Congressional Budget Office – Congress’ own nonpartisan scorekeeper – that approximately 22 million more Americans will be uninsured if the Senate bill goes into effect. An independent analysis provided for the Montana Health Care Foundation shows that Montana would lose over $5 billion in federal Medicaid funds, putting at risk coverage for thousands of low-income Montanans.

Here are some responses to statements made on Wednesday’s tele-townhall.

Eliminating Medicaid expansion will hurt many of those living in deep poverty, as well as, seniors in nursing homes and those living in their own home.

Senator Daines has indicated a couple times that he wants to protect those who Medicaid was originally designed to serve and lists “the very poor”, “the elderly under 65”, and “the disabled.” However, in many cases, those with very low incomes, including low-income seniors, were not eligible under traditional Medicaid, and it was Medicaid expansion that provided access to affordable coverage.

Previous to Medicaid expansion, an individual was generally only eligible for coverage if they had incomes below 50% of the federal poverty line and had children under the age of 18, or had a qualifying disability. Medicaid left out many low-income families who couldn’t access coverage elsewhere. During the debate on Medicaid expansion, we heard from many working parents with very low incomes who did not qualify for Medicaid but could not access affordable health insurance. We heard from many older Montanans who were living in deep poverty (and did not have young children) who did not qualify for Medicaid. Medicaid expansion has provided the life saving coverage for nearly 80,000 Montanans, many of whom Senator Daines has referenced in his examples. The Senate GOP plan will eliminate that coverage in 2021.

The Senate GOP plan will also gut traditional Medicaid, cutting over $5 billion in federal funds for Montana and likely forcing deep cuts to coverage and benefits.

Even if Senator Daines accepts the devastation due to eliminating Medicaid expansion, the additional cuts to traditional Medicaid will also hurt the very populations he has said he wants to protect. Medicaid provides health care coverage for nearly one in every three children in Montana. It provides critical health services for people with disabilities to stay in their homes and live with dignity.

The Senate GOP plan will cap federal funds provided to states to run their Medicaid programs, leaving states on their own to cover increased costs for health services. Federal oversight of Medicaid dollars guarantees that the most vulnerable Americans – like low-income children, seniors, and people with disabilities – continue to get the care they need. Under the Senate GOP proposal, spending on Medicaid would be capped or limited, and if a natural disaster occurred or public health crisis arose (like Zika or the current opioid crisis), the state would only be able to cover as many people as the annual lump sum would allow. Medicaid would no longer be a safety net program, with the federal government providing funding in response to state spending needs. Instead, states would have to come up with money themselves to cover any additional costs, turn people away, or make cuts to the people covered by the program.

Today, over 216,000 Montanans access health services through Medicaid coverage. If the Senate GOP plan becomes law, state policymakers would be left to their own devices to cut coverage for thousands of our most vulnerable neighbors.

The Senate GOP plan will leave thousands of Montanans, particularly those who are living on lower-incomes, sicker, and older, with no affordable option for coverage.

Senator Daines alleges that the Senate plan provides a “place to land” for those with lower incomes who are currently covered under Medicaid expansion, but this is far from true. Under the Senate GOP plan, these individuals would be eligible for tax credits to purchase health insurance on the Marketplace, but families would face greater costs and likely be purchasing insurance that provides less coverage.

Furthermore, many others Montanans accessing health insurance through the ACA marketplace will face greater out-of-pocket costs for worse insurance. Premium increases would be especially large for:

  • People in high-cost (read: rural) states. When looking at a comparison of how individuals in each state would fare, Montanans would, on average, see increased premiums that are the 10th highest in the country. This is because the across-the-board cuts to premium tax credits would disproportionately impact those in areas where health services and premiums are higher.
  • Older people with modest incomes. Older Americans are taking the brunt of the Senate GOP cuts, both through lower tax credits and through higher out-of-pocket costs for insurance. For example, a 60-year-old Montanan with income of $42,000 would see an increase in net premiums (after tax credits) of $5,492 to purchase the silver plan. Total reduction in tax credits is nearly $10,000.

Many of those who weren’t buying insurance in 2014 are now eligible for affordable coverage through Medicaid, but the Senate GOP plan would take away that coverage.

Senator Daines mentioned that approximately 35,000 Montanans paid the individual shared responsibility payment, and that roughly 14,000 of those are living on incomes below $25,000. It is important to note that this data is from 2014, before Montana expanded Medicaid. Prior to Medicaid expansion, those living under the poverty line (less than $12,000 for an individual, or less than $20,000 for a family of three) were stuck in the “Medicaid gap”, where they were not eligible for tax credits but also not eligible for traditional Medicaid. Montana’s bipartisan Medicaid expansion changed all that. Without access to Medicaid, lower-income families would be forced to buy insurance on the marketplace with less assistance and would be accessing less comprehensive insurance with greater out-of-pocket expense. In short, many of these Montanans would be back to where they were in 2014: with no insurance.

Montana’s bipartisan Medicaid expansion plan has saved the state millions of dollars and has provided a major lifeline for many of Montana’s rural hospitals.

 Senator Daines mentioned that the state is seeing greater enrollment in Medicaid expansion than previously projected and therefore increased costs. Without a doubt, Medicaid expansion has been a success.

Under the ACA, the federal government provides federal funding at 90% of the cost of coverage – a higher federal match than traditional Medicaid and federal highway dollars. This new coverage has also meant major savings for the state and for many hospitals and clinics that face high uncompensated care costs. In its first year, Medicaid expansion has saved the state of Montana over $22 million. Montana will continue to see savings. What would make Medicaid expansion untenable is the current Senate efforts to cut the federal match, putting at risk coverage for thousands of Montanans.

The massive cuts to Medicaid coverage will not help the ongoing opioid epidemic in the state – actually, it could get a lot worse.  

Since 2015, Medicaid has become our state’s primary payer for substance use disorder (SUD) treatment services and a critical
tool in combatting alcoholism, methamphetamine use, opioid abuse and overdose, and the myriad social consequences of addiction. In fact, since the passage of Medicaid expansion, Montana has seen a 67% increase in federal dollars going toward SUD treatment. Eliminating Medicaid expansion and cutting Medicaid dollars will make it more difficult for Montanans to access the treatment they need and could further devastate our families and communities.

These are important facts for Senator Daines and Montanans to know as the Senate continues to negotiate a potential bill that could rip health coverage away from tens of thousands of Montanans. Montanans made their voices heard this week during the tele-townhall, and we need to keep sharing our stories and concerns about what this bill would mean for Montana families.

The Senate Health Care Bill is Just as Bad as the House Version

The Senate Health Care bill, released on Thursday, jeopardizes Montanans’ health and well-being by deeply cutting Medicaid, raising premiums for many Montanans, and causing tens of thousands of hard-working Montanans to lose their insurance. The Senate took the deeply flawed House-passed American Health Care Act (AHCA) and “tweaked it.” In some ways, the Senate bill is even worse than the House AHCA.

While details are still emerging about the Senate bill, let’s take a look at the most important provisions, and how they affect everyday Montanans:

First, the Senate bill would end Montana’s bipartisan Medicaid Expansion program, causing nearly 80,000 people to lose access to care.

Montana’s bipartisan Medicaid expansion program is the first of its kind in the country by utilizing a third-party administrator to provide health care coverage to nearly 80,000 Montanans. The Senate bill will effectively end Montana’s Medicaid expansion program in 2021, by ratcheting down federal matching funds well below what ACA provided. Most of those newly enrolled are working at low wages and will be left with little or no options for affordable health insurance.

Second, the Senate Bill drastically cuts and caps the traditional Medicaid program.

Over 216,000 Montanans rely on Medicaid for health care including people with disabilities, seniors, and families with children. Eight in ten Montanans on Medicaid live in working households. Many of these hard-working Montanans, however, work at jobs that do not provide insurance. Despite the outcry over the House’s deep cuts to Medicaid (over $800 billion by 2026), the Senate bill’s cuts are even harsher over the long run than the House bill. Under the House version, Montana is expected to lose $4.8 billion in federal Medicaid funding – 35 percent of its current law funding – between 2020 and 2026. We have yet to see a full analysis of the Senate proposal by Congressional Budget Office, but the bill appears to cut an even greater amount of federal Medicaid funds over time.

Third, the Senate bill would raise premiums and deductibles for thousands of Montanans who buy insurance on the marketplace.

The Senate bill pulls the rug out from under Montanans who rely on the marketplace for reasonable health care coverage. Because Montana is a rural state, health care costs are higher here than in other parts of the country. While the Senate version does take into account income and regional costs of insurance (similar to what ACA does), the level of tax credits and assistance is below that in the ACA for many middle-income Montanans. Insurance costs, especially for older Montanans, would rise sharply under the Senate bill. Montanans would also likely face higher deductibles and out-of-pocket costs under the Senate bill. Approximately 117,000 Montanans rely on the Marketplace for affordable coverage, and many are in danger of seeing their insurance costs rise to unaffordable levels.

Fourth, the Senate bill allows states to strip away important consumer protections for people with pre-existing conditions and others most in need of care.

While the Senate version does not include the House proposal to allow states to waive protections for preexisting conditions, there are a number of other provisions that could have a devastating impact on the over 420,000 Montanans that live with a pre-existing condition. The Senate bill would allow states to waive certain protections, such as the ACA’s requirement that insurance plans limit people’s total out-of-pocket costs, which will disproportionately hurt those with pre-existing conditions. The Senate bill also allows states to waive certain health benefits, including access to, to maternity care, mental health care, or substance abuse treatment. With the opioid crisis spreading across Montana, a bill that reduces access to health care will only make the problem worse.

Conclusion

Because we are still waiting on a CBO score, it’s unclear exactly how many Montanans will lose insurance coverage under the Senate Bill. But make no mistake – this bill, like the one in the House, reduces coverage, increases health costs for many, strips consumer protections, and endangers Medicaid as well as the state’s own finances.

Montana’s senators should not support this bill due to the devastation it would cause for tens of thousands of Montanans. Anything less would break their promise to the people of this state.

House vs Senate Bill Checklist - Final[2]

Wonky Word: Substance Use Disorders (SUDs)

The debate continues around the House-passed American Health Care Act (AHCA) and now the Senate’s effort to craft a similar bill that will effectively end Medicaid expansion, dramatically cut Medicaid funding, and result in loss of coverage for millions of Americans. In our effort to continue to provide information on AHCA, we provided details earlier this week on what Essential Health Benefits (EHBs) are. One of these ten EHBs is mental health and substance use disorder (SUD) services, which includes behavioral health treatment. Substance use disorder, also known as drug use disorder, is a condition in which the use of one or more psychoactive substances leads to a clinically significant impairment or distress.

Substance use disorders are a nationwide problem, and Montana is all too familiar with alcohol and drug abuse. Montana residents have a higher rate of alcohol dependence or abuse than the national average, as well as a higher rate of untreated illicit drug dependence or abuse.

At the end of May, the Montana Department of Justice announced a new effort through the office’s Aid Montana initiative to gather input from Montanans regarding how best to address substance abuse. Over the summer, the Montana Department of Justice will partner with the Montana Healthcare Foundation to hold six listening sessions across the state to hear real life experiences of individuals affected by substance abuse.

These listening sessions should provide great feedback; however, there is one thing we already know: the Affordable Care Act and Medicaid Expansion funding provide the foundation to effectively addressing substance use disorders. The ACA and the state’s Medicaid expansion provide critical resources and services to those Montana residents battling addiction personally and the family members impacted by drug and alcohol abuse.

While we do not know what will be included in the Senate’s version, press reports indicate the Senate is sticking fairly close the House-passed bill, which would land a devastating blow to mental health and opioid addiction treatment due to the following components of the bill:

  • Dramatic cuts to Medicaid will cut billions in federal funds provided for substance use disorder treatment. Since 2015, Medicaid has become our state’s primary payer for SUD treatment services and Montana’s most potent
tool in combatting alcoholism, methamphetamine use, opioid abuse and overdose, and the myriad social consequences of addiction. In fact, since the passage of Medicaid expansion, Montana has seen a 67% increase in federal dollars going toward SUD treatment. A radical restructure of Medicaid, by converting it to a per capita cap will result in the loss of nearly $5 billion in federal Medicaid funds.  To compensate, Montana would have little choice but to cut eligibility, cut payments to hospitals and doctors, and/or cut benefits — including behavioral health services.
  • A return to pre-ACA coverage could result in the elimination of mental health and substance use treatment in private insurance plans. The AHCA allows states to waive certain essential health benefits, and this includes mental health and substance use treatment. Prior to ACA, almost no state required insurance companies to cover these services, and it is likely states will again start waiving these benefits.

As in most states, substance use disorder is a serious and growing public health problem in Montana. We can face this problem head on by maintaining the crucial federal Medicaid funds to pay for substance use disorder treatment. We can’t afford to lose this lifeline to recovery in Montana.

Wonky Word: Essential Health Benefits 

During recent weeks, you have probably heard the term Essential Health Benefits repeatedly as Congress continue efforts to repeal and replace the Affordable Care Act (ACA). Right now, the Senate GOP leadership is cooking up their version of a health care bill behind closed doors and could take a vote before the July 4th recess.

The House-passed GOP plan eliminates Medicaid expansion and dramatically cuts Medicaid funding. Congress is also considering measures to allow states to waive the essential health benefit rules within the ACA. What are “Essential Health Benefits” and why have they become so central in the debate around health insurance coverage in America?

Essential Health Benefits (EHBs), also called federal minimum benefit standards, are at heart of the ACA. EHBs outline a set of ten categories of services that health insurance plans must cover at minimum. States must also provide EHB to beneficiaries eligible under the ACA’s Medicaid expansion, and plans may offer additional benefits such as dental and vision coverage.

Prior to the ACA, it was up to each respective state to determine what benefits (called insurance mandates) had to be included in insurance plans. Not surprisingly, states differed widely in terms comprehensiveness required, and no specific benefit was deemed essential in all 50 states and Washington, D.C.

EHBs provide coverage that offers viable protection against some of the most basic health care costs Americans experience and were designed to provide marketplace consumers with insurance coverage similar to the coverage of employer-sponsored insurance and Medicaid.

So, every health plan must cover the following services1: 

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
  • And these two additional benefits:
    • Birth control coverage (contraceptive methods and counseling for all women)
    • Breastfeeding coverage (breastfeeding equipment and counseling for pregnant and nursing women)

Before the ACA, most health insurance frequently did not cover these basic services. For example, in 2011, among people in the individual market:

  • 62 percent had plans that didn’t cover maternity care;
  • 34 percent had plans that didn’t cover substance use treatment;
  • 18 percent had plans that didn’t cover mental health; and
  • 9 percent had plans that didn’t cover prescription drugs.

Under the GOP’s replacement plan, comprehensive insurance, with benefits like maternity or mental-health coverage, could become unaffordable—if not unavailable.

If the Essential Health Benefit standards were eliminated, individual and small-group market plans would quickly revert to the pre-ACA status quo and would likely:

  • Leave people who have pre-existing conditions without the coverage they need. People with pre-existing conditions — who need services like substance abuse treatment,mental health services, or comprehensive prescription drug coverage — often wouldn’t be able to find the coverage they need at any price, much less an affordable one.
  • Charge women more than men for coverage. In practice, eliminating Essential Health Benefit requirements means that women would once again be charged more than men, since they’d have to pay more for plans with maternity coverage — if they could even find a plan.
  • Burden even insured people with unaffordable bills and medical bankruptcies. Before the ACA, millions of people had health insurance that wouldn’t actually cover them if they got sick. Plans often had annual and lifetime limits on coverage and no limits on individuals’ out-of-pocket costs, and they omitted key services.The ACA fixed this by prohibiting annual and lifetime limits and setting an annual limit on what enrollees can be required to pay out-of-pocket for deductibles and other cost-sharing. Eliminating the Essential Health Benefit standards would make these rules meaningless.

SNAP Improves Outcomes for Montana’s Kids

Elizabeth The Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) helps Montana families put food on the table and make ends meet. But we also know that it accomplishes much more than that. SNAP is actively improving our children’s futures.

Research increasingly shows that SNAP can protect children against the long-term effects of experiencing poverty and food insecurity, events that take a toll not only on immediate well-being but can impact children’s economic and social mobility into adulthood. Nearly 20% of Montana’s kids live in poverty and just over 18% live in food insecure households, putting them at risk of poorer health outcomes, reduced nutrition, lower academic achievement, and increased behavioral issues.

Hungry kids often have trouble focusing, which makes it hard for them to pay attention at school and retain information. And parents who are too busy worrying about where their next meal will come from don’t have enough time or energy to focus on their child’s education. Studies show that young children whose families qualify for and receive SNAP are at lower risk of developmental delays than children from similar low-income families who do not receive food assistance from SNAP.

SNAP helps form a strong foundation of health and well-being for low-income children by lifting millions of families out of poverty, improving food security, and helping improve health and academic achievement. SNAP delivers more nutrition assistance to low-income children than any other program. In Montana, SNAP helps about 48,700 children each month, or more than 1 in 5 of our state’s kids.

In addition, more Farmer’s Markets are accepting SNAP, which helps families to access fresh, local produce and ensures their kids have the right nutrition to thrive. In Montana, SNAP is accepted at 23 Farmer’s Markets, a growing number of which also offer ‘double SNAP dollars’, an incentive program that doubles the dollar amount SNAP customers can spend on fresh produce.

SNAP is helping to give thousands of Montana children the foundation they need to succeed and the fuel they need to thrive. Efforts to reform or enhance the Supplemental Nutrition Assistance Program should build on its effectiveness in protecting the well-being of our children, and preserve the essential program features that contribute to that success.

Elizabeth Weaver, SNAP Outreach Coordinator, Montana Food Bank Network

Myth Busting: What is really at stake with Medicaid and AHCA

Last week there were two articles quoting Senator Daines on health care and the continued effort in the Senate to repeal and replace the Affordable Care Act: Senator Daines Urged To Protect Medicaid and Daines and Tester weigh in on status of ‘Obamacare’ repeal in U.S. Senate. Some of the statements made about Medicaid were inaccurate, and we want to provide additional context on how Medicaid works and its importance to accessing health services in Montana.

MYTH #1: The original Medicaid program focused on those in deep poverty and seniors below the age of 65.

FACT: In fact, before passage of ACA, Medicaid left out many low-income individuals, including most seniors living in poverty. Montana’s bipartisan Medicaid expansion provides health coverage to those exact populations.

Before the Affordable Care Act and Montana passed Medicaid expansion, Medicaid did not cover the very poor unless they were disabled or had children under the age of 18-years-old. This left tens of thousands of Montanans below the poverty line uninsured. Additionally, Medicaid did not take care of older adults who were under 65 unless they qualified due to a disability, meaning that low-income seniors between 50-64 often did not qualify for Medicaid.

Montana’s bipartisan Medicaid Expansion plan has provided access to health care coverage to nearly 80,000 low-income Montanans, including seniors, adults, and others.

 

MYTH #2: Congress should give states more flexibility to administer their Medicaid programs.

FACT: States already have significant flexibility in how they run their Medicaid program, and cuts to federal Medicaid funding will only make it harder for states to provide access to coverage and benefits.

In exchange for the federal funds, states must meet federal standards that reflect the program’s role covering a low-income population with limited resources and often complex health needs. The federal standards largely focus on requiring states to cover certain groups, such as poor children and pregnant women, as well as certain core benefits.

However, states can choose to cover additional groups, offer enhanced benefits, and already have wide latitude over many aspects of the program, particularly how they pay providers and structure their delivery systems. States can use Section 1115 waiver authority to vary from the federal standards and state options to address different priorities and emerging issues.

The programs across states vary widely in terms of who is eligible, what benefits are covered, what premiums and cost sharing are charged, and how providers are paid and care is delivered.

 

MYTH #3: Medicaid expansion can be protected if the phase out of the higher federal match occurs over several years.

FACT: Any phase-out of the higher federal match for Medicaid expansion will end Medicaid expansion in Montana.

The House-passed AHCA eliminates the higher match of federal funds for those who would be newly enrolled after 2019. The Senate is considering a longer phase-out, but to be clear: this has the same effect. CBO estimates that more than two-thirds of those enrolled in the Medicaid expansion would fall off the program within two years and that fewer than 5 percent would remain on Medicaid after six years. For those who see their income drop after phase out, the state would not receive the higher match and would most likely no longer be able to afford to continue to provide Medicaid to this population.

 

MYTH #4: Medicaid creates a disincentive to individuals to seek employment or employment opportunities with higher wages.

FACT: Among adults with Medicaid coverage—those most likely to be in the workforce—nearly 8 in 10 live in working families, and a majority are working themselves.

Nearly half of working Medicaid enrollees are employed by small businesses, and many work in low-wage industries that do not offer employer-paid insurance. Since the majority of Medicaid expansion enrollees are low-wage workers, Medicaid expansion prevents them from falling into the coverage gap; it helps them cope with high turnover in the low-wage labor market.

Medicaid expansion and the tax credits and subsidies under ACA provide a smoother transition to private Marketplace coverage. This has been particularly important for Montanans living in rural communities, accessing Medicaid and insurance on the marketplace at a greater rate. When their earnings rise or they get a new job, they can transition to employer coverage or the ACA marketplaces. Under ACA, the tax credits and subsidies provide significant support to lower costs for marketplace coverage. And families have the security of knowing that Medicaid will be there for them again if they lose their job, see their hours cut, or face financial crisis. Additionally, when they no longer qualify for Medicaid but live at 139% of the poverty rate, individuals can currently qualify for a tax subsidy to help pay the health insurance premium.

By eliminating Medicaid expansion and cutting tax credits for low-income families, the AHCA (and likely any iteration from the Senate) will create a situation where many families may have to choose between employment and keeping health insurance. For example, a family who earns $20,000 in Montana will see their premium paid after tax credit rise by 295% for a total of $3,690. That is the equivalent of 15% of that family’s income.

Mother’s Day: What Moms need is health care

We hope moms and moms-to-be around the state had a wonderful Mother’s Day.

Because we love our moms and we are a female-led organization, our team spent time looking into how the House GOP bill to repeal and replace the Affordable Care Act (ACA) might affect women, and moms specifically.

The ACA changed the landscape for women’s health insurance coverage. As we await the Senate’s version of a bill, it is crucial to understand the particular damage that ACA repeal poses for women’s health and economic security.

We know that much attention has been given to the provision of the AHCA that allows states to waive the “essential health benefits” coverage for individual market plans. Which basically means that pregnancy, c-sections, or injuries from domestic violence are included as pre-existing conditions and subject moms and women to significantly higher premiums.

However the issue of fundamentally changing Medicaid is equally as detrimental to moms in our state and country. As it stands, the House health bill would have devastating consequences for the nearly 40 million women across the country who rely on Medicaid. In Montana, 129,200 women are enrolled in Medicaid and 35% of births are financed by Medicaid.

The House-passed bill would slash Medicaid by more than $800 billion over ten years by effectively eliminating Medicaid expansion to low-income adults and imposing a “per capita cap” on the program.

Women would bear a disproportionate impact of these cuts because they are not only the majority of Medicaid beneficiaries, but are also the primary utilizers of family planning and maternity care, benefits that could be eliminated with devastating federal cuts to Medicaid.

In addition, Medicaid expansion gave many women not raising children access to coverage and offered continuous coverage to new mothers who had qualified while pregnant but would not have qualified after their pregnancy. Ending the expansion would take these benefits away.

There are a few other benefits the ACA gave women that could be lost with repeal. One is breastfeeding. The ACA covers lactation support and counseling, equipment and supplies, such as pumps, and infrastructure, such as pump rooms and break time. The other is access to birth control which provides health benefits for women and children, improves women’s ability to control whether and when they have a child, and fosters women’s ability to participate in education and the workforce on an equal footing with men. The ACA was a total game-changer when it comes to access to birth control for women because it removed the cost barriers. Women no longer have to pay out-of-pocket costs or choose between paying for birth control and paying for other necessities, like groceries and utilities.

The ACA and Medicaid have been hugely beneficial for women’s health. With the potential repeal hanging above us, women – and mom’s – have a lot to lose. While the future is uncertain, we want to make sure that women and moms continue to have access to affordable health care. We encourage all moms, women, and the men in their lives to contact our Montana Senators and tell them to reject any health bill that causes people to lose coverage, caps or cuts Medicaid, ends the Medicaid expansion, or takes away critical protections.