Montana records largest drop in childhood Medicaid coverage from pre-pandemic figures, study shows

Montana had a 27% drop in childhood Medicaid enrollment from April to December 2023, the second highest in the nation, according to a new report that evaluates how states handled post-pandemic Medicaid eligibility throughout much of last year.

The study, authored by researchers at the Center for Children and Families at Georgetown University, finds that childhood Medicaid enrollment dropped by more than four million nationwide during eligibility redeterminations in 2023. That figure does not include all children who lost Medicaid coverage but were later able to re-enroll, experts said Thursday.

The report shows that more than 133,000 children were covered by Montana Medicaid programs in April 2023, the month that redeterminations began. But by December, enrollment numbers had dropped to about 97,800. Montana’s 27% caseload reduction was one percentage point behind South Dakota’s, which led the nation in that metric.

Montana Gov. Greg Gianforte and his appointed leadership at the state health department have defended the state’s handling of Medicaid redeterminations. Overall, more than 134,000 people lost coverage between April 2023 and January 2024, with 63% removed for procedural reasons rather than ineligibility, according to the state health department’s public dashboard.

In a statement Thursday about the Center for Children and Families report, a spokesperson for Gianfore said overall Medicaid enrollment had returned to pre-pandemic levels over the course of redetermination, with about 222,000 people covered as of January.

“The governor has been clear that the safety net must be intact for the most vulnerable who truly need it, including for children and families,” said spokesperson Kaitlin Price. “DPHHS’ federally required redetermination process reviewed the eligibility of program enrollees to ensure those who are ineligible are no longer on it.”

Gianforte’s appointed director of the state health department, Charlie Brereton, has referenced the same trend in recent public comments and hearings with state lawmakers. But the Center for Children and Families report shows that, in regards to children, December 2023 enrollment was lower than it was before the pandemic began.

The report summarizes that in February 2020, Montana had roughly 115,000 children enrolled in Medicaid and the Children’s Health Insurance Program. The December enrollment figure of about 97,800 shows a roughly 15% reduction.

Joan Alker, a Georgetown research professor and executive director of the Center for Children and Families, said in a press conference Thursday that Montana was one of eight states that “disenrolled so many children in 2023 that they had fewer children enrolled at the end of the year than prior to the pandemic.”

“This is a troubling finding, given that the world was not a perfect place for children’s insurance coverage prior to the pandemic,” Alker said. She described Montana’s 15% reduction, the most of any state, as a “very troubling distinction.” The next highest-ranking states of Idaho, South Dakota and Arkansas had 6% reductions, less than half the decrease seen in Montana.

Heather O’Loughlin, the executive director of the Montana Budget and Policy Center, which advocates for public policy that supports low-income Montanans, said Montana’s figures can be traced back to the state’s handling of the redetermination process.

“Montanans who needed assistance with their redetermination paperwork encountered barrier after barrier,” O’Loughlin said. “With [the health department’s] failure to change course and improve assistance, it is no surprise that thousands of Montana children are without health insurance.”

In a statement Thursday evening, a spokesperson for the health department did not comment directly on the findings in the report but urged the public not to draw conclusions about the redetermination process until the state can issue a final report on the outcomes.

 “This process has meant ensuring the most vulnerable have access to the resources they need while also protecting taxpayer resources from intentional or unintentional program abuse,” spokesperson Jon Ebelt said.

Children are typically more likely to be eligible for Medicaid than adults, Alker said Thursday, raising concerns that the large numbers of minors who have been removed from the public health insurance were cut because of administrative red tape rather than true loss of eligibility. She pointed out that North Carolina and Kentucky paused disenrollments for children during the unwinding period in an effort to avoid removals. 

“Primarily the [states’] governors are ultimately responsible for how millions of children are faring during this process,” Alker said. “States have many choices, and these choices are reflected in the data we’re presenting today.”

Public health advocates often point out that Montana’s Medicaid programs help improve outcomes for enrollees and reduce health care costs long term. In a 2024 report on Medicaid in Montana released at the end of April, the Montana Healthcare Foundation found that people with chronic health conditions and substance use disorders visited the emergency department less often the longer they had health care.

Dr. Kimberly Avila Edwards, a Texas provider and representative of the American Academy of Pediatrics Committee on Federal Government Affairs, told reporters Thursday that the loss of Medicaid coverage for children is clearly impacting how families seek and obtain health services, a point that Montana providers have also raised in recent months.

“The impacts of the Medicaid unwinding are now painfully visible to pediatricians every day,” Edwards said. “Babies are missing well-visits, in which we monitor and keep their development on track. Children are losing vital home-health services and are unable to see needed pediatric care specialists. And families are foregoing vital care for their children and teens for fear of financial devastation.”

Edwards and Alker urged state governments to reach out to families whose children have lost coverage and re-enroll anyone who remains eligible for the public program.

The Gianforte administration and the Montana state health department have not announced plans for such an outreach campaign. The health department has said it will continue processing Medicaid applications for anyone who submits one. Price, with the governor’s office, said Montanans who believe they are eligible can visit apply.mt.gov.

Cover Montana, an arm of the Montana Primary Care Association, announced partnerships in early April with local community organizations to help re-enroll as many eligible people as possible, or help them transition to other insurance plans. 

Mara Silvers is a reporter for the Montana Free Press, a Helena-based nonprofit newsroom, and can be reached at msilvers@montanafreepress.org.