If the Republican bill on Montana Medicaid expansion became law, it most likely would eliminate Montana Medicaid expansion.

The reason is the poison pills tucked into page 44 of House Bill 658:

  • Section 48 says, "It is the intent of the legislature that each part of [this act] is essentially dependent upon every other part, and if one part is held unconstitutional or invalid, all other parts are invalid."
  • Section 49 says, "If the Centers for Medicare and Medicaid Services fails to approve the waivers needed to implement the provisions of [sections 1, 2, and 5] in the manner approved by the legislature, then [this act] is void."

House Bill 658 would add numerous requirements for Medicaid enrollees to work at least 80 hours a month, to report their work or their exemptions from work and would kick people off the program if they failed to follow all the rules and meet all deadlines.

Work requirements proposed by the state of Kentucky have already been ruled illegal once by a U.S. district judge, who is expected to rule by April 1 on Kentucky's latest attempt to show in court that its complex work requirements don't interfere with the purpose of Medicaid, which is to provide health care. The same judge, James Boasberg, is hearing a case against Medicaid work requirements in Arkansas where 18,000 people have been dropped from the state program because they didn't file the work requirement documentation as demanded by Arkansas — even though they were working and eligible for the program based on low income.

At a hearing last week, a skeptical Boasberg questioned U.S. Justice Department attorneys about whether the work requirements approved by the Trump administration helped to achieve Medicaid's goal of promoting health coverage, according to Kaiser Health News.

If HB658 became law as written and its work requirements were thrown out by judicial review — a distinct possibility — the entire law would be void, there would no longer be Medicaid expansion coverage.

The other poison in HB658 is the stipulation that CMS, the federal agency that administers Medicaid, would have to approve all of the many requirements in the legislation as written — or else the law would be completely nullified.

In fact, CMS never approves state requests for waivers or changes exactly as states submit them, Mary Dalton, former longtime Montana Medicaid director, told the House Human Services Committee on Saturday. Getting an agreement from the federal agency to let states deviate from federal requirements is always a negotiation, Dalton said.

HB658 includes numerous restrictions that CMS refused to approve for the state of Arizona, Dalton said. For example, CMS doesn't allow states to kick eligible people off health care for an entire year as HB658 mandates. HB658 requires parents to work even if their children are too young to be home alone and offers no assistance with child care.

There is a better choice. House Bill 425, introduced by Rep. Mary Caferro, D-Helena, would simply remove the sunset from Montana Medicaid expansion to continue the health care while beefing up the HELP-Link program that has already boosted employment among low-income Montanans.

The numerous restrictions and work requirements in HB658 are along the lines of the Arkansas plan that has been disastrous for the people of that state.

Montana already has a good model, the HELP Act of 2015, which reduced the state's uninsured rate, increased workforce participation among low-income adults and helped financially struggling Montana hospitals reduce their charity and bad debt losses. Montana hospitals have already agreed to be taxed to cover the state's net costs of continuing to cover 96,000 low-income Montanans. Seventy percent of those folks are already working and 80 percent live in a household in which somebody works, according to Department of Labor and Industry data. The Montana model already encourages work and has minimized red tape and administrative costs.

Let's keep this essential health care going for Montana employers, low-income workers and the health care providers who take care of us when we are sick or injured — regardless of our ability to pay. Legislators, please support HB425, the simple lifting of the Medicaid expansion sunset.

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