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Whether they like it or loathe, Montanans are talking about Medicaid in this election year.

Since the GOP majority in the 2013 Legislature rejected plans to cover 70,000 uninsured, low-income Montanans with Medicaid, the number of people enrolled in this program has increased by about 10,000.

State authorities estimate that includes about 2,000 children and 1,000 adults who found out they qualified when they or their parents checked out the federal health insurance exchange. The rest of the growth reflects the steady increase seen as Montana’s population increases.

As of last week, 145,000 Montanans were covered by Medicaid or Healthy Montana Kids, according to the Department of Public Health and Human Services. Nearly 74 percent (107,000) are children. Most of the rest are low-income, disabled adults or elders residing in assisted living or skilled nursing facilities.

Montana Medicaid only covers certain categories of poor people. Among those left out are:

 Low-income workers. Childless, able-bodied, working-age adults don’t qualify no matter how poor they are.

 For impoverished parents, Montana Medicaid can give an incentive to stay jobless. To qualify for Medicaid, a parent of a minor child can have income no greater than 52 percent of poverty level, or about $10,000 a year for a family of three.

 Most women covered by Medicaid during pregnancy aren’t covered before the pregnancy and lose coverage weeks after their babies are born.

“We know we’ve got to do reform,” said state Sen. Roger Webb, R-Billings, one of eight Republicans who have been meeting monthly in Helena to consider health care changes that don’t involve expanding the present Montana Medicaid program.

The group is interested in models that would use private insurance to cover low-income workers and would share cost risk with health care providers.

Privatization pros, cons

Private insurance ideas are worth exploring. However, Montanans should remember the mental health managed care debacle that occurred in the late 1990’s when the state turned over all of its mental health services to a private company. Seriously ill Montanans weren’t able to get needed care, Montana mental health providers didn’t get paid and the state didn’t save money as had been hoped. Privatization isn’t always better.

Speaking last week in Billings to mental health advocates, DPHHS Director Richard Opper appealed: “Elect people to the Legislature who support expanding Medicaid.” The group of about 40 people from Billings and Easter Montana applauded. Montana needs to be “expanding Medicaid in one form or another,” Opper said, adding that our state “could use Medicaid money to pay for premiums like Arkansas.”

Montana Republicans and Democrats have talked with Arkansas officials.

Gov. Steve Bullock’s health policy adviser, Tara Veazey, said recently that “all options are on the table.”

Montana Medicaid should be reformed so that it covers all low-income Montanans up to 138 percent of poverty level. Above that level, Montanans can afford to buy federally subsidized private insurance policies under the Affordable Care Act.

Reduce cost shifting

The Montana plan should provide incentives for adults to work. However, it makes no sense to cut out jobless people, as some Republican lawmakers have proposed. If sick, impoverished, unemployed Montanans can’t get health care, how quickly can they recover and get jobs?

Montana hospitals provide millions of dollars in charity care annually. Most of that charity cost must be covered by hospital operations, which means patients who can pay end up paying for the indigent in higher hospitals bills and higher insurance premiums. In counties with health care levies, the cost of charity care is directly subsidized by local property taxpayers. We should be getting better value for our money.

So long as 70,000 Montanans lack insurance and can’t pay for the care they need, the costs will be shifted to the rest of us. How much better it will be to cover these Montanans with a system that is more accountable and focused on consistently high-quality care.

The governor and lawmakers in this great state must agree on a way to cover everyone. That will reduce cost shifting and allow Montana providers and health insurers to bring comprehensive techniques for quality care and cost reduction to a population now poorly served by sporadic, high cost, uncoordinated care.

All Montanans deserve access to the right care at the right time.