Montana lawmakers approved a Medicaid plan backed by the state's Democratic governor despite an aggressive campaign by Americans for Prosperity, a conservative lobbying group funded by the billionaire Koch brothers.
On Thursday, the Republican controlled House voted 54-46 to approve the legislation, with 13 Republicans and all 41 Democrats supporting it. The bill needs one more vote before it goes back to the Senate, which already approved it but must ratify an appropriations amendment. Gov. Steve Bullock is expected to sign the legislation, a spokesman said.
About 70,000 people would become eligible for coverage if Montana expanded Medicaid to adults with incomes up to 138% of the federal poverty level.
The plan, which requires a CMS waiver, includes copays and premiums totaling up to 2% of a person's income. Participants also would be offered assistance to either find employment or a better-paying job.
Time is running out for state legislatures to take action on the issue this year, leading some Medicaid advocates and policy experts to think it was too late for any more states to make the leap in 2015.
“The progress made in Montana speaks to the momentum on this issue,” said Katherine Howitt, senior policy analyst for Medicaid issues at Community Catalyst, a consumer advocacy group in Massachusetts. She said she remains optimistic about Alaska, Utah, and Florida also possibly expanding this year.
“I'm ecstatic, we were really holding our breaths. (The bill) passing the House was a true miracle and it took a lot of dedicated individuals,” said Amy Aguirre, a consumer advocate and board member for Montana Organizing Project, a coalition that supported expansion.
Hospitals are also thrilled. “There are a number of small hospitals in Montana that on any given day are in jeopardy, where they're trying to figure out how to keep their doors open,” said Dick Brown, president of the Association of Montana Health Care Providers.
There were many attempts to derail expansion, including a campaign backed by the well-funded Americans for Prosperity.
“To put it bluntly, they have money," said Sheena Rice, chief lobbyist for the Montana Organizing Project, which supported the bill.
The bill that ultimately passed in both chambers of the Montana Legislature was introduced by Republican state Sen. Edward Buttrey.
“I was told personally by people from Americans for Prosperity, 'we will take you out, we will make your life miserable,'” Buttrey said, noting that the threats were political, not criminal, in nature.
He said his colleagues received similar threats and were asked to sign pledges to oppose the plan.
Levi Russell, director of public affairs for Americans for Prosperity, said the organization "does not make threats, but we certainly promise to hold lawmakers accountable for their votes, and to educate citizens on the positions their elected officials have taken.”
What happened in Montana will continue to play out in other states that have not yet expanded Medicaid, experts say. The conservative group has been credited with derailing expansion in Tennessee and Kansas, and continues to fight in Florida to keep House Republicans on its side.
“It's very unfortunate that this has become a battle with the Republican party between well-funded ideologues and more pragmatic Republicans,” said Joan Alker, executive director of the Georgetown Center for Children and Families.
Buttrey said he was able to get other Republicans to back his proposal by positioning it as an economic engine. The bill, he told them, would help not only to get people better, but help get them out of poverty by getting them skills they needed to get and keep a job. He also said it would create jobs, mostly in the healthcare industry.
Buttrey also put some teeth in the bill to ensure there would be skin in the game from beneficiaries. Beneficiaries with incomes above 100% of the federal poverty level who do not pay premiums would have their debts sent to collections and ultimately their coverage would be terminated.
The lowest-income beneficiaries would not be kicked out of the program for failure to pay premiums. The CMS has it made clear in responses to other state proposals that it won't approve such provisions. The state will, however, make attempts to collect debts from those beneficiaries.
Buttrey estimates thousands of eligible Montana residents won't sign up for coverage because of the cost-sharing requirements.
“It's a difficult thing to accept for people this poor, making no more than $16,000 a year,” said Rice, the lobbyist for the Montana organizing project. “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.”