Medicaid changes loom with Trump election

As Montana’s Medicaid expansion turns a year old next month, supporters and opponents are looking to the act’s future with the looming possibility of national health-care reform.

Since the HELP Act rolled out last January more than 61,000 Montanans have secured health coverage, surpassing original estimates of 45,000 enrollees by 2020. The expansion assists people with health coverage who are living at 138 percent of the federal poverty level. That works out to a family of four living off roughly $33,000 a year.

Sen. Ed Buttrey, R-Great Falls, introduced the act with the HELP-Link workforce program woven into the plan.

“Most states measure success on how many people are on the program,” Buttrey said. “If we can find the barriers to better employment … we can help people get off the program and out of poverty.”

Buttrey’s sales pitch was enough for state lawmakers to narrowly pass the act in 2015.

Sen. Bob Keenan, R-Bigfork, was never sold on the idea. Weeks before the program went into place, Keenan reserved a placeholder for a bill to scrap the expansion.

“I put the bill draft request in as a wake-up call to those who passed it, that [repealing it] is an option,” Keenan said.

But with less than a month before the state Legislature meets in Helena for its 2017 regular session, Keenan said he’s now counting on national reform to chip away at the state’s Medicaid expansion.

His hope rests on President-elect Donald Trump, who has called for repealing and replacing the Affordable Care Act — the funding source for the state’s expansion.

“Now, with the presidential election, I don’t have any intent to introduce that bill,” Keenan said. “Why fight your enemies when they’re already standing on a ledge?”

ABOUT 10 percent of HELP Act enrollees start in the HELP-Link voluntary job training program, according to the program’s oversight committee, of which Keenan and Buttrey are both members.

The percentage shrinks further when looking at how many people actually complete HELP-Link. Keenan points to those numbers as an example of the program’s failure.

“The job piece is showing, these people signing up for free health care are not interested in taking care of their health or bettering their lives,” he said.

Commissioner Pam Bucy with the state’s labor department is charged with pulling people into HELP-Link.

“Of the people who have gone through the program, 83 percent found employment and showed a 42 percent increase in wage … That’s extremely successful,” she said.

Two-thirds of people who qualify for the expansion have jobs. The challenge is connecting those people with Job Service to learn about ways to move from economic survival to stability, Bucy said.

“For a lot of people, they hear ‘Job Service’ and think, ‘That’s not for me, I’m not unemployed,’” she said. “We’re still working to change that.”

Bucy said the number of people engaging in HELP-Link has increased by 91 percent in the last four months as the program has leveled out. She said those numbers match, or surpass, similar government programs.

Buttrey said for the program to survive, that’s not good enough. The expansion’s design relies on people leaving the assistance so the state’s burden isn’t too large, he said.

The HELP Act saved Montana more than $10 million in its first year since the federal government picked up its cost, according to the state’s health department. But in January, Montana will shoulder 5 percent of the cost. Buttrey said since enrollment numbers change, it’s difficult to translate that percentage into a dollar amount.

“HELP-Link’s not failing, it’s just getting started. But this needs to be our focus going forward — make sure it doesn’t fail,” he said.

Keenan said the unknown expense comes as Montana’s budget is thinning due to state tax collections falling well below expectations.

“People look at the enrollment of 61,000 as a silver lining,” Keenan said. “But I’m a budget man … that [enrollment] is about a one-third increase over what the fiscal note projected.”

NATIONALLY, health-care insurance costs have skyrocketed as more people with medical conditions enter the market. Trump has often pointed to the Affordable Care Act as the root of the problem.

Bryce Ward, the director of health-care research at the University of Montana, said he typically wouldn’t think it would be possible to repeal the Affordable Care Act.

“Getting rid of health insurance for over 20 million people seems like something that would be hard to pull off,” he said. “But we’re outside of the normal realm right now of how things work.”

During Trump’s campaign, the incoming president said he would block-grant Medicaid to the states. That means states are given a certain amount of funding for health insurance. If the state’s medical needs surpass the federal allocation, it’s on the state to pay the difference.

Ward said if the nation does transition to block granting, Montana could see less funding for its health care.

But he said right now, it’s not clear if this plan will come to life, “and any major change is probably months or years away.” And, he said, it will likely come well after the Montana Legislature finishes its session in April.

Keenan said he likes the idea of Montanans being able to shape a program that works well for the state — especially through block-granting.

“Now, we may not have the money to fill these programs we’ve started, but I see that as good news. These programs have been disincentives for people to get jobs and off assistance,” he said.

Buttrey said if that’s the route the federal government takes, he’s worried large portions of the expansion won’t last. But, like Ward, he said no one is certain which direction a Trump cabinet will go.

Buttrey said the HELP Act was built to survive big changes in the Affordable Care Act — premiums can rise to help pay for funding if federal funding decreases, he said. And if upcoming changes give states the ability to run their own program, he would like to see HELP-Link become mandatory to insure its success.

“We hear good stories every day about people the expansion is helping — it’s doing what we intended it to do,” Buttrey said. “We’ll just have to adjust with the Feds. No one knows where we’ll be a year from now … if we can’t afford it, we’ll have to find different solutions.”