Montana not ready for Obamacare repeal

The Republican from Culbertson recently told The Gazette that state lawmakers would have to figure out a way to dial back the state’s Medicaid program humanely. More than 60,000 people have signed up for Medicaid since the 2015 Legislature voted to offer Medicaid to more than 70,000 working Montanans who at the time couldn’t afford insurance but were too far above the poverty level to qualify for Medicaid.

That expansion depends on a federal subsidy that covers nearly all of the program’s cost, which this year is $201 million, according to the state Department of Public Health and Human Services. The state can’t afford the expanded program, Knudsen said, but it can’t rip the health care coverage away from participants.

“You’re going to tell me that we’re going to put 100,000 people on the Medicaid rolls and then when the federal government takes the money away we're just going to jerk the rug out from under them? I don’t see that as being a realistic answer,” Knudsen said. “The state of Montana is going to have to look at trying to help keep those people covered. Whether I like the bill or not, it passed. It was signed into law. We covered a whole bunch more people.”

Medicaid expansion passed largely on the votes of Montana Democratic lawmakers with enough Republican support to get it approved with a narrow margin of support. The program was officially offered for the first time in January 2016. By mid-November, 60,123 newly eligible Montanans had signed up for Medicaid, according to DPHHS.

President-elect Donald Trump has vowed to scrap the Affordable Care Act, commonly referred to as Obamacare, which congressional Republicans have been attempting to repeal for years, calling it unaffordable and a drag on the economy.

U.S. Sen. Steve Daines, R-Mont., is a vocal critic of the Affordable Care Act. He told The Gazette that legislation to repeal the ACA will come early next year, but that it may take two to three years to end the health care program. Republicans plan to replace with something else, although what it would be is only being depicted in broad strokes.

Republicans are going to have to bake time into their replacement health care proposals, Daines said.

“We need to provide a two- to three-year glide path,” Daines said. “We will have a transition that clearly assures that the Montanans that are on Medicaid aren’t harmed on this transition.”

Republicans have discussed replacing health care subsidies, for things like Medicaid, to states with block grants that would allow states more freedom in how the money was spent. Those block grants would certainly be worth less than the amount of current subsidies.

The ACA hasn’t worked as planned, Daines said. He points to the number of insurance companies getting out of state organized health exchanges for the uninsured as proof the ACA is failing.

If the first repeal actions to ACA were to come within two years, Montana could be caught without a plan for dealing with the transition. The state Legislature meets every other spring and creates a budget for the coming two years. The budget crafted in the first four months of 2017 will set state government spending through June 30, 2019.

If Congress hasn’t acted by the end of the 2017 state Legislature, special action might be needed, Knudsen said. But he said there isn’t a practical way to plan without knowing first what the federal government might do. Gov. Steve Bullock, a Democrat, said the same.

“It would be grossly irresponsible to rip healthcare away from tens of thousands of Montanans and millions of Americans without presenting a real and viable alternative that patients, providers, states and insurers can all plan around,” Bullock said in an email. “Republicans in Congress have had six years to think about and plan for fixes, replacements, and alternatives. We can’t speculate on a state response until those plans are clear.”

Bullock recently wrote U.S. House Majority Leader Kevin McCarthy, R-Calif., asking that ACA not be repealed before an alternative has been created.

Since 2013, changes under the Affordable Care Act have decreased the rate of uninsured Montanans from 20 percent to 7 percent, Bullock told McCarthy. Rural hospitals that have lost money serving the uninsured and underinsured have been better compensated.

There are 52,000 Montanans younger than 65 with pre-existing conditions that could lose coverage if the ACA mandate that everyone qualify for insurance be eliminated.

When the Montana Legislature approved Medicaid expansion in 2015, it wrote into the law that the coverage would end if the federal subsidy fell below 90 percent. That doesn't seem responsible now, Knudsen said.