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Gazette opinion: When will Montanans get HELP?

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How many Montanans will gain health coverage through the 2015 HELP Act before the Legislature reconvenes in January 2017? 20,000? 40,000? More? Fewer?

The answer depends on when the state’s Medicaid expansion connects with low-income Montanans ages 19-64.

Montana’s plan for covering all very low income adults with Medicaid is a mixture of health care expansion and political compromise.

To enact a law that makes 70,000 Montanans eligible for Medicaid, health coverage proponents had to agree to charge monthly premiums to impoverished people and to contract with a private company to administer the coverage and premium collections.

The state must convince federal health authorities that the usual provisions of federal law should be set aside to let Montana demonstrate how its plan works.

The Centers for Medicare and Medicaid Services should grant Montana the waivers. The agency has already allowed similar exceptions for five other states.

Exceptions for 5 states

Arkansas, Iowa, Indiana, Michigan and Pennsylvania all received waivers to charge premiums or monthly contributions to Medicaid expansion enrollees, according to the Kaiser Family Foundation. These charges have been about 2 percent of enrollee income, which is what Montana law requires.

Although none of the other waiver states is using a third-party benefit administrator as Montana proposes, the state of Arkansas is providing premium assistance for Medicaid eligible people to buy private insurance policies on the exchange, said Robin Rudowitz, a Medicaid policy analyst at Kaiser.

A Kaiser Foundation review of research on how premium charges affect low-income enrollment in health care found “potential savings to states related to these measures, but also the potential risk of increased barriers to access care, increased unmet needs, worse health outcomes, substitution of more expensive care for more efficient care, increased burdens for safety-net providers and increased administrative costs.

In some cases, the administrative costs of collecting premiums from poor people exceed the amount collected.

Montana also is asking CMS to allow enrollees to be eligible for 12 months, instead of cutting them off any month their income goes up. People need insurance year round.

Year-round coverage

When Anna Whiting Sorrell was Montana DPHHS director, she saw the effects of “churning” on Medicaid enrollees. Many people work seasonal jobs and have periods of unemployment annually, she said. They would qualify for Medicaid and then lose it when their seasonal work boosted their income.

“People in poverty need health care,” said Sorrell, now director of operations for Confederated Salish Kootenai Tribal Health.

Some states use 12-month eligibility for children and parents on Medicaid, Rudowitz said, adding: “It’s quite effective for managing continuity of care.”

A Montana Department of Public Health and Human Services request for proposals says the state wants the health care coverage to start Jan. 1. Several things will need to happen quickly to meet that target.

After the state’s 60-day public comment period on its Medicaid waiver proposals ends next month, the waiver request will go to CMS, which will set its own 30-day comment period. No one is guaranteeing when the waiver will be granted. Meanwhile, the state will need to contract with a private company to administer the program.

Then 70,000 extremely low income Montanans will be eligible for Medicaid, including about 20,000 Native Americans.

Bullock, Tester lead the way

Expect these folks to sign up gradually. Most haven’t had insurance or Medicaid, so it’s not necessarily something they think about – until they get sick or injured. The majority of signups are likely to be through efforts of Montana health care providers who see patients regardless of their ability to pay. John Felton, CEO at RiverStone Health, has said that about 8,000 of the clinic’s clients will be eligible for Medicaid when it expands.

In a state of 1 million citizens, covering 70,000 will be a huge benefit. The HELP act will create jobs, improve the health of parents, young adults and other low-wage workers, and provide a lifeline to people who can’t work until they get well.

Gov. Steve Bullock and U.S. Sen. Jon Tester must keep up their personal efforts to move the waiver process along expeditiously. U.S. Rep. Ryan Zinke and Sen. Steve Daines ought to be helping, instead of talking repeal. Their constituents’ lives and health will benefit from Medicaid expansion.

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