Health Care for Montana’s American Indians Uncertain

The state will be considering whether to keep its Medicaid expansion, putting health coverage of thousands of American Indians on the line.

Montana Gov. Steve Bullock
AP Photo/Matt Gouras
Nov. 15, 2018, 8 p.m.

More than 15,000 American Indians in Montana could lose health coverage and be cut off from preventive services if state officials fail to extend the Medicaid expansion past its June 2019 expiration date.

Montanans last week defeated a ballot measure that would have permanently expanded Medicaid in their state. The proposal would have increased taxes on tobacco products to establish long-term funding for the coverage, and its defeat now leaves the program's future in the hands of state officials as they consider whether to keep the expansion.

As of September, more than 96,000 adults had enrolled in Medicaid expansion, representing 9.4 percent of the state population.

“Faced with the most expensive opposition to a ballot measure in Montana history, I’m encouraged by the thousands of doctors, nurses, hospitals, veterans, and Montana families who were not deterred and came together to fight for our Montana values,” said Gov. Steve Bullock in a statement after the measure was defeated. “The fight to protect healthcare for 100,000 Montanans isn’t over and we won’t give up. There’s too much at stake.”

The governor is proposing to reauthorize Medicaid expansion, but he will have to work with the Republican-held legislature next year to have it extended. If state officials do not extend the program, experts and advocates fear that coverage gains in the American Indian population will be reversed.

Montana, where 8 percent of its 1 million residents are American Indian, had the highest number of uninsured American Indians among states in 2009, with 43 percent lacking coverage, according to an analysis done by Kauffman & Associates.

Since the state expanded its Medicaid program, 15,288 American Indians have enrolled and the Indian Health Service has been able to increase its services using expansion revenue, said an August report to the governor from the expansion’s oversight committee.

“American Indians now have greater access to preventative treatment (such as a colonoscopy) which can reduce the need to seek treatment later on for an advanced disease when the chance of survival is minimal,” the report states. “This is important if we are to change the fact that American Indians die 20 years younger than Whites in Montana.”

Before expansion, health centers on Indian reservations could not afford to provide support for preventive services and instead focused on services that directly treated life-threatening conditions.

“The federal government’s health care clinics and hospitals on the reservations—that’s the Indian Health Service—have been operating at what’s called a life-and-limb-only referral priority for decades,” said Aaron Wernham, CEO of the Montana Healthcare Foundation.

“What that means is if you walk into a clinic on a reservation and want to get a colon-cancer screening, or have had intermittent problems with gallstones, or have torn your ACL in your knee and can’t work because of it, you were not going to get a referral,” Wernham added. “You weren’t going to get any elective procedure like that paid for by the Indian Health Service because they only had enough money in their budget to pay for life-or-limb-threatening things.”

Montana Republicans have already begun sharing ideas they plan to consider in the discussion to continue Medicaid expansion. New House Speaker Greg Hertz this week laid out some changes lawmakers will review, according to Montana Public Radio.

“We will be reviewing that throughout the legislative session,” Hertz said Wednesday. “And yes, we’ll be looking at work requirements, asset testing, and possibly some other restrictions, too, on Medicaid-expansion participants.”

Work requirements in Medicaid have been promoted by the Trump administration, but critics are concerned that such requirements would cause people to be thrown off the program. Montana health care experts said that work requirements would likely not be effective for the state.

“When you create rules, you create structure; somebody has to then enforce those rules,” said Bryce Ward, director of the Health Care Research Program at the University of Montana’s Bureau of Business and Economic Research, who described work requirements as a “money-losing proposition.”

“The burden of that administration falls on both the recipient—thus you’re actually making it harder for them to get jobs because now they have to deal with the bureaucracy of demonstrating that they’re trying to get work ... and the state has to pay to administer it,” Ward added.

Ward said Montana’s current work-assistance program, in which Medicaid enrollees fill out an assessment to identify barriers to working and job-service staff help match enrollees with services to remove those barriers, has been effective. More than 25,200 Medicaid-expansion participants have received workforce services, according to the oversight committee report.

David Herbst, state director of Americans for Prosperity’s Montana chapter and a critic of the Medicaid expansion, said he doesn't think adding work requirements will push more people into the workforce, saying that the current work-assessment program has been underutilized.

"The work program that’s already in the bill is not really being utilized; only 20 percent of the people who are in Medicaid expansion utilize that,” he said. “There’s almost no evidence that they transition into a full-time job and get out of that program."

Herbst said he is concerned that Medicaid expansion long-term is unsustainable and he would rather the legislature focus on policies that create competition in the insurance market.

But Bullock is pressing for the expansion to continue in the budget he released Thursday, noting that Montana’s overall uninsured rate is down to 7 percent from 20 percent in 2013. “Governor Bullock believes it is essential to protect Medicaid expansion from repeal to ensure that nearly 100,000 Montana seniors, veterans, and families don’t lose healthcare coverage and to keep the doors of rural hospitals open and rural communities healthy,” an overview of his budget states.

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