Just when supporters of Medicaid expansion were feeling disheartened, the Republican-led legislature in the rugged individualist state of Montana revived their spirits. On Friday, Montana lawmakers narrowly pushed through a coverage expansion to an estimated 70,000 adults with incomes up to 138% of the federal poverty level. They did so over strenuous opposition from a well-funded conservative group backed by the billionaire Koch brothers. That group has threatened Republican lawmakers with political retribution.
The success of the Montana expansion effort, spearheaded by Democratic Gov. Steve Bullock, comes as Medicaid expansion appears to have died this year in Tennessee and Wyoming and is struggling in Florida, Alaska, and Utah.
Montana hospital leaders were thrilled, given the financial difficulties facing the state's smaller rural facilities. But supporters had to hold their noses and accept provisions that even the bill's Republican sponsor, Sen. Edward Buttrey, said would discourage thousands of low-income residents from signing up, according to a report by Modern Healthcare's Virgil Dickson.
The bill, which will have to win waiver approval from the Obama administration, imposes premiums and copayments of up to 2% of a person's income for those with incomes above the poverty level. Beyond that, Buttrey said that if beneficiaries don't pay their premiums and cost-sharing amounts, their unpaid bills will be sent to collections—even for people with incomes below 100% of poverty.
That took some of the joy out of the victory. “It's a difficult thing to accept for people this poor, making no more than $16,000 a year, said Sheena Rice, chief lobbyist for the Montana Organizing Project, which backed the bill. “Even $30 a month is going to be a strain on their budget. But we needed to do this so they would be able to get access to healthcare.”
It's remarkable that the issue of extending health coverage to low-income Americans—most of whom are workers or are part of working households—has become so contentious in so many states. In Florida, Republican Gov. Rick Scott's nominee for state surgeon general, Dr. John Armstrong, was so skittish about the issue that he repeatedly refused to answer questions from incredulous state Senate Republicans about his views on their bill to expand Medicaid. Last week Scott came out against expansion, after coming out for it, after originally opposing it.
“As a physician, you have no opinion as to whether additional health care coverage is good for outcomes?” Sen. Don Gaetz asked Armstrong during his confirmation hearing.
“I am mindful of the thoughtful conversations that are occurring in the Legislature and carefully reflecting on how those conversations and results will ultimately impact the health of the people of Florida,” Armstrong replied.
After his series of evasive answers, angry Senate Republicans postponed consideration of his confirmation.
What may be behind conservatives' resistance to Medicaid expansion is they are thinking ahead to their big plans for sharply cutting Medicaid spending and turning Medicaid into state block grants if they win the White House and hold on to Congress in next year's elections, as Modern Healthcare's Dickson reported. Such plans are included in the budgets recently passed by the GOP-controlled House and Senate.
“The more general fear is that changes to the Medicaid program are inevitable,” Yevgeniy Feyman, a fellow at the conservative Manhattan Institute, told Dickson.
But expansion opponents may want to consider the words of Ohio's Republican Gov. John Kasich, who made the following comments while locked in a ferocious fight with state GOP lawmakers over Medicaid expansion in 2013. He won that fight but now has to convince them to renew the expansion program.
“The most important thing for this legislature to think about: Put yourself in somebody else's shoes. Put yourself in the shoes of a mother and a father of an adult child that is struggling. Walk in somebody else's moccasins. Understand that poverty is real.”
Kasich continued: “I had a conversation with one of the members of the legislature the other day. I said, 'I respect the fact that you believe in small government. I do, too. I also know that you're a person of faith.
'Now, when you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small. But he is going to ask you what you did for the poor. You better have a good answer.' ”