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21 May 2013

Medicaid expansion options for Montana’s progressives

The Legislature’s failure to approve Medicaid expansion both threatens affordable health care for as many as 70,000 Montanans, and leaves supporters of Medicaid expansion with four political options, none good:

  1. Do nothing. Let the poor and sick seek treatment in hospital emergency rooms, as they now do, and hope they can find ways to purchase private insurance policies on the federal health care exchanges.

  2. Defer the issue until the 2015 legislative session. Concentrate on electing more progressives to the legislature.

  3. Call a special session of the legislature in 2013 or 2014. As a practical matter, this requires cutting a deal before the session, keeping the deal together during the session, and doing the dealing with the same legislators who shot down Medicaid expansion during the 2013 legislative session.

  4. Put the issue on the 2014 general election ballot as a citizen’s initiative. Bypass the legislature, go directly to the voters, as was done in 2008 with I-155, the Healthy Montana Kids Plan Act, which passed with 70 percent of the vote (329,289 to 141,701).

Doing nothing

As House Speaker Mark Blasdel explained to the West Shore News on 13 March, doing nothing is the Republican plan:

Blasdel believes that the people who would be covered under any Medicaid expansion could also get subsidized health insurance through a new federal health care exchange that is being created as part of the Affordable Health Care Act.

The state of Montana decided in the 2011 legislative session to not give the state auditor the authority to create a state-run exchange, Blasdel said.

Blasdel believes that any able bodied person who makes $11,190 or more per year — up to 200 percent of the federal poverty level — will be eligible to go to the federal health insurance exchange and get a 100 percent federally subsidized tax credit that can be used to purchase insurance. Those who make between 200 and 400 percent of the poverty level would be eligible for a less-than-100 percent subsidy, Blasdel said.

“It will be all federal money and the state is not on the hook long-term,” he said.

Kicking the can to 2015

Waiting until the 2015 legislative session condemns the needy to at least one additional year of going to the emergency room without any guarantee that the legislature will approve expanded Medicaid in Montana. In fact, the next legislature may not be as progressive as the 2013 legislature.

A special session

If Governor Bullock and the dozen or so self-described Responsible Republicans can cut a deal, and find a way to keep the deal from being buried in a committee or otherwise undone, this is the best option. It would expand Medicaid the soonest, and require a veto override in 2015 to undo the expansion.

Going directly to the voters

The more I think about this option, the less I like it. An initiative does have advantages — a clean expansion of Medicaid instead of a bastardized scheme like Arkansas proposed; and, as with a successful special session, making expansion something the legislature has to take away instead of approve — but it’s very risky. Any comparison with I-155 must be tempered with the experience of the 2010 debacle and the knowledge that the voters in the 2014 midterm election will more conservative than in a Presidential election. If the initiative is defeated at the polls, the legislature will not come to the rescue and the door to Medicaid expansion will be nailed shut for a very long time.