This tax bill is a health care bill too.

We anticipate that the House and Senate will vote on the final GOP tax plan early next week. While this proposal is first and foremost a give-away to the super wealthy and corporations, it’s important to remember that it is also a direct attack on the health care coverage of Montanans.

We briefly explained in an earlier post about why the Senate tax bill would hurt Montanans with health care needs. Today we are going to take a closer look at how this tax bill is a health care bill too:

If the Affordable Care Act’s individual mandate were repealed, 13 million more Americans would go uninsured. While the Congressional Budget Office (CBO) notes that the magnitude of the coverage effects is uncertain, it concludes that there’s no doubt that “the number of uninsured people would be millions higher.”

In Montana, 146,717 people are enrolled in Medicaid as of September 2017, and 86,000 people are enrolled in Montana’s Medicaid expansion as of November 2017.

And, thanks to the Affordable Care Act, Medicaid and the Children’s Health Insurance Program (CHIP), 92 percent of Montana’s children now have health insurance coverage.

With over 232,000 Montanans insured through Medicaid and Medicaid Expansion, cuts to Medicaid would be devastating for our state. Montana is already grappling with an opioid epidemic, as well as major funding cuts to support rural health care needs and Montanans with disabilities. As recent media has reported, Medicaid and Medicaid Expansion has been a critical lifeline for Montanans.

Without the ACA individual mandate, individual market premiums would also increase 10 percent. Fewer healthy people would sign up for individual market coverage with no mandate, which would increase average costs and therefore premiums in the individual market as less healthy and young people enroll and more people with expensive medical needs tilt the cost of health care needs.

The Congressional Budget Office (CBO) estimates that repealing the mandate would permanently raise premiums by 10 percent, and some major insurers have projected larger effects. As Senator Collins has noted, these premium increases would likely erase — or more than erase — the Senate bill’s tax cuts for millions of people who buy coverage in the individual market. Unaffordable premiums should not be a barrier to folks who need coverage.

The individual mandate is also critical to keeping the individual market stable. As the American Academy of Actuaries commented in its recent letter to Senate leaders about repealing the mandate, “increased uncertainty and instability regarding future enrollment, premium rates, and risk pool profiles if coverage incentives are eliminated would increase the risk of insurers incurring losses. Insurers would likely reconsider their future participation in the market. This could lead to severe market disruption and loss of coverage among individual market enrollees”

And last, but not least, if repealing the individual mandate is included in the final federal tax plan, it would also result in the loss of $5.5 million in general fund revenue per year for Montana. Since it is predicted less Montanans would enroll, the state would lose revenue from no longer collecting the health insurance premium tax from enrollees.

Affordable health care coverage for Montanans is a value that we all share. Our Montana congressional delegation should work to advance tax policies that strengthen the state of Montana and invest in our working families. Equally, our congressional delegation should support health care legislation that strengthens the Affordable Care Act—not provisions that work to cut it down.

Open Enrollment & the Alexander-Murray Bill

Open Enrollment for 2018 begins tomorrow, November 1st, and this year the enrollment period is shorter — lasting for only six weeks—from November 1st until December 15th.

The Affordable Care Act has been the target of countless efforts of repeal and replace, as well as direct sabotage from the Trump administration. However, going into the 2018 Open Enrollment, the ACA is still in place.

The Alexander-Murray bill is currently the only plausible bipartisan market stabilization package to strengthen the ACA in Congress. The Congressional Budget Office found that Alexander-Murray would benefit both consumers and federal taxpayers by reducing individual market premiums beginning in 2019 and reduce deficits by $3.8 billion over ten years – while maintaining coverage rates.

The legislation would:

  • Guarantee cost-sharing reduction (CSR) payments to insurers through 2019;
  • Restore a significant portion of the Trump Administration’s cuts to ACA marketplace outreach and enrollment assistance;
  • Expand eligibility for so-called “catastrophic plans,” which are high-deductible plans that are subject to ACA rules and consumer protections but are currently available only to people under age 30; and
  • Simplify and alter some aspects of the ACA’s “Section 1332” waivers, which allow states to modify certain provisions of the ACA as long as the waivers cover as many people, provide coverage at least as affordable, provide coverage at least as comprehensive, and do not increase the federal deficit.

By guaranteeing payment of CSRs, the agreement would lower individual market premiums, prevent insurer exits, and save the federal government money – next year, and even more so in 2019.

By restoring funding for outreach, the agreement will help hundreds of thousands of people get coverage they need and help keep premiums low for all consumers, since outreach is especially important to encouraging healthy people to buy insurance.

While the Alexander-Murray proposal is not perfect, it is a step in the right direction. Most importantly, it signifies progress toward bipartisan action on health care, and away from damaging efforts to repeal the ACA, radically overhaul Medicaid, and take away coverage from millions of people.

We need swift, bipartisan Congressional action on this front in the passage of Alexander-Murray. The sooner this agreement is enacted into law, the more it will do to help consumers and strengthen markets in 2018.

During this enrollment period, call Senator Daines and Senator Tester, and ask them to reject calls from the White House, from Senator Hatch and Congressman Brady, and others to undermine the Alexander-Murray bill. We cannot risk the coverage of millions of Americans and destabilize the individual market with continued partisan health care games.

Alexander-Murray Bill: Stabilizing the health insurance market is key to affordable health care

Earlier this week, Senators Alexander and Murray announced an agreement on a bipartisan bill to stabilize the individual health insurance market. While the Alexander-Murray bill isn’t perfect, it marks an important first step toward bipartisan action on health care, and away from damaging efforts to repeal the ACA, radically overhaul Medicaid, and take away coverage from tens of thousands of Montanans.

Governor Bullock should be commended for supporting this bill and for laying the groundwork for the agreement through his work with governors of both parties. When the governors released their health care “blueprint” in August, they showed it is possible to reach bipartisan agreement on proposals that can strengthen the individual market and make coverage more affordable for consumers.

This bill would also directly benefit Montana’s consumers. By guaranteeing payment of CSRs, the agreement would lower individual market premiums, prevent insurer exits, and save the federal government money – next year, and even more so in 2019. By restoring funding for outreach, the agreement will help hundreds of thousands of people get coverage they need and help keep premiums low for all consumers, since outreach is especially important to encouraging healthy people to buy insurance. 

Some of the provisions in the Alexander-Murray bill do raise concerns. For example, its changes to waivers go beyond those proposed in the bipartisan governors’ blueprint, and could increase the risk that waivers in some states could make coverage less affordable for some people. And, the bill is also only an initial and incomplete response to the Trump Administration’s actions undermining the ACA marketplaces.

Congress should guarantee CSRs permanently, not just for two years, to provide greater certainty and stability to the market. And, Congress should address the harmful actions foreshadowed by the Administration’s recent executive order, which would raise premiums, destabilize the individual and small group markets, and undermine protections for people with pre-existing conditions.

Overall, however, the bill represents significant progress. In addition to the bipartisan group of ten governors, including Governor Bullock, numerous patient, provider, consumer and insurer groups support it. It has two-dozen Senate co-sponsors from both parties.

Some House and Senate Republicans, along with the Administration, are rejecting the Alexander-Murray bipartisan stabilization package for the partisan Hatch-Bray proposal, which attempts to hold CSR payments hostage for a renewed version of a “skinny ACA repeal” bill.

Senator Daines should reject the harmful Hatch-Brady proposal and offer his support to the Alexander-Murray bill so that Congress and the President can enact it into law without delay. The sooner this agreement is enacted into law, the more it will do to help consumers and strengthen markets in 2018.

Who exactly is covered under CHIP in Montana?

At the end of September, Congress allowed funding for the Children’s Health Insurance Plan (CHIP) to expire. While Montana has funds to keep the program running for the next few months, the state is expected to run out of federal funds in early 2018. The failure of Congress to act before then will put thousands of Montana children at risk of losing their insurance coverage.

But exactly who is at risk of losing coverage has garnered some questions. In Montana, federal CHIP funds create the program known as Healthy Montana Kids (HMK). HMK has two parts – HMK and HMK Plus. The benefits and network of providers are relatively the same for both plans.

For the time being, coverage under HMK Plus is likely to continue because the state is required by federal law to maintain this coverage. However, without action by Congress, coverage through HMK is almost certainly at risk.

Parents can tell which program their children are enrolled in by taking a look at their kids’ insurance cards. Those with insurance cards for HMK include the logo for Blue Cross Blue Shield and are potentially affected by CHIP funding expiring. Children whose cards say Medicaid or HMK Plus are in the Medicaid program and are not affected. Images of the two different insurance cards can be found on the DPHHS site.

Each program has certain income eligibility requirements, based on the federal poverty level data. Below is a chart that provides a comparison of who is covered in each of the programs.

While the Medicaid portion is not at risk with Congress’ failure to extend CHIP funding, in the past the state has received more federal funds for some of these children. Without an extension to CHIP, the federal government will pay less for the 7,000 children in this group. The state will still provide coverage, but will face increased costs.

Chip Chart


Unlike children’s Medicaid and HMK Plus, coverage through HMK is at risk of ending if Congress does not extend funding. If Congress does not act, Montana will run out of federal funds by early 2018. At that point, it could choose to continue to provide coverage using state funds, but it would cost roughly $96 million per year in state funds to maintain that coverage.

Alternatively the state may be forced to cut coverage or end the program. This means tens of thousands of children in Montana are at risk of losing their health care coverage in early 2018 if Congress does not act quickly.

What has CHIP and Healthy Montana Kids meant to your family? Share your story with Montana’s members of Congress and tell them about the impact that HMK has had on your family.

Montana children’s health coverage in jeopardy

Federal funding for the Children’s Health Insurance Program (CHIP), which covers tens of thousands of children in Montana, expired on September 30, 2017. Unless Congress acts soon to extend this funding, the state of Montana will soon need to make tough decisions on how to maintain this critical coverage for Montana children. And it won’t be cheap.

Earlier this year, Senators Orrin Hatch and Ron Wyden (the Finance Committee’s chairman and ranking Democrat) actually worked out a bipartisan agreement to extend federal CHIP funding through fiscal year 2022. But the last ditch effort to repeal the Affordable Care Act (Graham-Cassidy bill) derailed efforts to extend federal funding for CHIP. The consequences of this delay will hurt our state and our children. Montana is set to exhaust CHIP funds within the first three months of 2018. It could happen as early as January.

More than 1 in 3 children are covered through Healthy Montana Kids (HMK) – the state’s Medicaid and CHIP program. HMK, which includes both children’s Medicaid and CHIP, not only improves children’s health, it also has lifelong impacts on physical and financial well-being.

Montana uses CHIP in two different ways: through a combination of a separate CHIP program and a CHIP-funded Medicaid expansion. This means a lack of CHIP funding hurts Montana in two different ways.

First, states with CHIP-funded Medicaid expansions would be required to maintain this coverage under the Affordable Care Act (ACA) maintenance of effort requirement, but with far less federal funds to do so. Montana will need to find state funding for the nearly 7,000 kids covered by HMK Plus – the CHIP-funded Medicaid expansion population – if CHIP is not reauthorized. States receive a higher federal match for kids on the CHIP-funded Medicaid expansion than they do for kids on regular Medicaid. The state must continue to cover these kids, despite receiving a lower Medicaid federal match. State costs would increase substantially.

Second, states with separate CHIP coverage would not be required to maintain this coverage if federal funding ends – putting coverage in danger for thousands of Montana children. Unless Congress acts soon, over 23,000 kids in Montana are at risk of losing coverage as the federal funding runs out in early 2018.

Montana, like most states, assumed continued federal funding in the state budget, as well as the continued ACA enhanced match. Our state will be left with even fewer federal dollars and Montana is already facing an enormous budget crisis. Without federal funding, Montana would face increased budget pressure, children would lose coverage, and implementation of program changes could result in increased costs and administrative burden for states as well as confusion for families.

If states close enrollment and/or end separate CHIP programs, some children could shift to parents’ employer-sponsored plans or Marketplace plans, but others would lose insurance altogether. Previously, some states closed enrollment in CHIP for limited periods in response to state budget pressures, and studies show that this led to coverage losses, left eligible individuals without access to coverage, and had negative effects on health and family finances.

If Congress does not act quickly to preserve children’s health care, Montana’s elected officials and families will be forced to make difficult and painful decisions. For more details on the importance of CHIP in Montana, check out our fact sheet: Montana Families Rely on the Children’s Health Insurance Program.

ACA Defense is a Marathon, Not a Sprint

The latest bill to repeal the ACA is by far the most destructive.

Remember the Better Care Reconciliation Act (BCRA) and the Affordable Health Care Act (AHCA) from earlier this summer? Well, ACA repeal is back with a vengeance and the replacement option is bad news for Montana.

With just five days left to repeal the Affordable Care Act (ACA) using the current reconciliation bill (which allows Republicans to pass the measure 51 votes in the Senate), Senators Graham and Cassidy are still working hard to try to get enough support to pass their repeal bill. Although Senator McCain dealt a major blow to their efforts when he came out in opposition to the bill last week, the President, Senate Republican leadership, and the bill sponsors appear still to be working hard to gain the necessary 50 votes. That means this week is a critical moment for Montanans to make sure our congressional delegation hears what is at stake for Montana.

This Graham-Cassidy bill is just as destructive – if not more – than any of the previous GOP-proposed health care laws.

What would Graham-Cassidy mean for Montana?

Graham-Cassidy would eviscerate protections for Montanans with pre-existing conditions and punish states like Montana, by cutting federal resources for expansion states.

The bill would convert the funding for ACA insurance subsidies and Medicaid expansion into an inadequately funded block grant for the first 10 years, at which point funding would be eliminated entirely. During the first ten years, the block grant would decrease overall federal funding below current law and redistribute large amounts of the remaining funding from expansion states like Montana to certain non-expansion states. The block grant also fails to provide flexible funding to deal with unexpected events like recessions or natural disasters.

A recent report from Manatt Health and the Robert Wood Johnson Foundation estimates that the block grant provision of Graham-Cassidy would result in a loss of $1.5 billion in federal funds to Montana by 2026.

But it gets worse. Graham-Cassidy also fundamentally alters the basic Medicaid program by creating a per capita cap for all of Medicaid (not just expansion), dramatically cutting funding to states for seniors, people with disabilities, and very low-income families. Recent accounts suggest that both Alaska and Montana may be exempt from the first 10 years of the per capita caps. However, according to recent estimates by AARP, from 2027 to 2036, when the per capita caps are in place, Montana would lose an estimated $2.6 to $6.4 billion from the caps.

In 2027, when the block grant funding ceases while per capita caps continue, federal funding to states will drop by almost $300 billion below current law in that year alone. Coverage for hundreds of thousands of Montanans is at risk, including American Indians, people with disabilities, seniors, and children.

Why the big push before September’s over?

The GOP-led Senate is ramming through this last-ditch effort to repeal the ACA because under the existing reconciliation bill, the Senate only needs a simple majority (including Vice President Pence as a potential tie-breaker) to pass ACA repeal legislation. The current reconciliation bill expires on September 30, after which the Senators who want to repeal the ACA would need 60 votes to overcome a filibuster.

Senate Majority Leader Mitch McConnell has said that the Senate will take a vote this week. We hope to see the CBO score early this week, but because of the rushed timeline, it is unlikely to have comprehensive numbers regarding potential premium increases or loss of coverage. It’s unconscionable that any public official would vote for a bill with such wide-ranging consequences for our health care system without a full understanding of its effects.

Let’s reenergize for one more week to stop this repeal and hopefully get closer to the end of this marathon battle to protect affordable health care in Montana. Our congressional delegation needs to hear from all of us.

More state budget cuts could be on the horizon: How much more can our communities take?

The Montana Budget and Policy Center staff spent their weekend pouring over the 10 percent reduction plans submitted by each state agency to the governor’s office. These plans, totaling over 220 pages, provide a glimpse at how painful these cuts could be for services for Montana families and support for schools, local law enforcement, and counties.

It’s important to note that these proposed 10% reduction plans are coming on top of $218 million in cuts that happened during the legislative session and this summer.

As we’ve discussed in previous blogs, according to the governor’s budget office, the state now faces a $227 million shortfall. In order to restore the ending fund balance back to where it needs to be, the governor and legislature can make further cuts and/or find new revenue. While the governor has some authority to make cuts on his own, the law limits him to cutting no more than 10% in each agency program. In order to reach the $227 million, the governor would have to take the full 10% of cuts in nearly every program.

In other words, if the governor and legislature do not come together to find additional revenue, the governor may be forced to address the budget crisis entirely through cuts and would have to accept nearly everything contained in the agency reduction plans. In that scenario, the Department of Health and Human Services (DPHHS) would experience the largest cut. According to the department’s reduction plan, the general fund cuts total $105 million and would also result in the loss of $135 million in federal funds, for a total loss of $240 million.

Potential cuts to DPHHS include:

  • Eliminate health case management for foster children, provided by Missoula and Cascade County Health Departments and Riverstone Health (Billings).
  • Eliminate supplemental payment to foster parents caring for infants and toddlers to help defray costs for diapers.
  • Cut orientation and mobility skill instruction for 300 children with low vision or blindness.
  • Cut grants for child care providers that help improve quality care.
  • Cut over $2 million in funding for non-profit organizations in Billings, Missoula, and Helena that provide housing and support for teenage mothers.
  • Eliminate partnership with Children Advocacy Centers that provide multidisciplinary evaluation of children victims of violence. This work and cost would be shifted back to local law enforcement agencies.
  • Eliminate funding for mentoring of foster children through eight Big Brothers Big Sisters organizations across the state.
  • Cut funding to domestic violence shelters across the state.
  • Cut $400,000 provided to tribes to assist with foster care placement of tribal children currently in their care.
  • Cut an additional $48 million in targeted case management for individuals with disabilities and those experiencing mental health and substance use disorders (this is in addition to cuts made earlier this year).
  • Eliminate funding for services for developmentally disabled and at-risk children ages 0-36 months.
  • Eliminate Medicare prescription drug benefits for over 10,000 low-income seniors.
  • Cut $6.8 million in services for home and community-based services for seniors and people with disabilities who want to stay in their home or community, likely forcing more Montanans into nursing home care.
  • Cut $8.5 million in hospice services.
  • Cut $15.5 million in personal assistant services for seniors and people with disabilities living in their own home.
  • Eliminate health insurance coverage for direct care workers who are already struggling to make ends meet.
  • Cut $23 million in reimbursement rates for hospitals providing care to Medicaid patients, including cuts to payments for Montana’s rural critical access hospitals. These cuts could mean reduced access to services in rural Montana.
  • Eliminate Medicaid’s coverage for some dental services, which could impact over 44,000 Montanans and 585 dentists providing coverage to Medicaid patients.
  • Cut $1.6 million in chemical dependency treatment.
  • Reduce grants to counties for mental health crisis intervention.
  • Close 19 offices of public assistance in rural Montana, impacting many families’ ability to access assistance and services.
  • Leave significant number of staff positions vacant through biennium (between 8% and 18% of positions in each division will be left unfilled).
  • For some remaining Department staff, mandatory furloughs that will cut hours by 7% to 12.5%.

This list is just cuts to DPHHS. Make no mistake, every program in every agency is facing cuts, but there is time to do something about it. The governor and legislators must come together to find a balanced solution to this crisis. Otherwise Montana is set to take a total of $500 million in general fund cuts in this biennium.

While some cuts may be inevitable, common sense measures to increase the tobacco tax and close tax loopholes would mitigate deeper cuts that will hurt our communities. These proposals should be part of the conversation. There are solutions to ensure that our tax system is fair, raise critical revenue, and help Montana be the state we all love to live in.

Focus on American Indian Youth During Suicide Prevention Month

September is National Suicide Prevention Month. Throughout the month, mental health advocates, prevention organizations, survivors, allies, and community members will unite to engage the general public about suicide prevention and the ways we publicly invest in suicide prevention efforts.

For almost forty years, Montana has had one of the highest suicide rates in the country. Death by suicide among non-Native populations peaks in older adulthood, whereas suicide among Native populations peaks during adolescence. In Montana, American Indian youth are almost four times more likely to die by suicide than their white counterparts.

Youth suicidal risk assessments for 2015 show that urban-residing American Indian youth consistently outscored reservation-residing American Indian youth in risk behaviors such as seriously considering, planning, and attempting suicide. In April we published a report Indian Country Suicide Prevention: A Critical investment in Our Communities, where you can find more information about American Indian suicide rates in Montana.

Montana’s staggering statistics, especially among American Indian youth, warrant a serious investment and should be a priority for the state of Montana.

In 2013, the Montana Legislature established the first suicide mortality review team of its kind in order to review every suicide death in an attempt to identify specific causes and tailor prevention efforts accordingly. Two years later, Governor Bullock developed an initiative to reduce suicide among Native American youth in Montana, securing $250,000 through the legislature.

The Montana Department of Public Health and Human Services (DPHHS) began efforts with a formal tribal consultation, which evolved into a statewide coalition meeting in order to develop a strategic plan. The Montana Native Youth Suicide Reduction Strategic Plan is the result of the coalition and Governor’s efforts in 2015, which was presented to state officials in January 2017.

During the 2017 session, several bills were proposed to confront the suicide epidemics among American Indians, veterans, Native youth and at-risk Montana communities. Ultimately, the Governor signed a bill to allocate $1 million for suicide prevention efforts through 2019.

This month is a time for us to consider how we invest in our most important resource: our fellow Montanans – and especially our youth. To get involved, check out your local newspaper for details on activities and events happening in your area.

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.