The early draft of a bill to continue Medicaid expansion in Montana would continue the program without increasing costs to the state by expanding a tax to more health insurance companies, increasing premiums for some people covered and charging a new assessment for some religious groups that are organized as corporations.
Rep. Ed Buttrey, a Republican from Great Falls, will carry his party's bill to continue Medicaid expansion. The draft released Wednesday also includes what Buttrey calls "community engagement" provisions that require work, volunteer hours or other mandates such as participating in substance use disorder treatment, to be covered under Medicaid expansion.
Buttrey cautioned that the bill is still a very early draft and could change before it's introduced.
"We've really all along been about the principal of skin in the game. If you're benefiting from the program, you need to help the program to succeed," Buttrey said of his approach. He said his bill does that for all the parties involved, from individuals to insurance companies and hospitals.
Medicaid expansion has been a good deal for the state, Buttrey said, by improving health outcomes for people, increasing their personal income and job potential, and saving money because the federal government pays a higher share of the cost.
"This has been an economic boon for Montana, especially when you consider we have workforce participation by this population. We want that to continue. We don't want to get to the point where the cost of the program exceeds the benefits and revenue of the program, so in essence we're capping what the current costs (are)," Buttrey said.
How Montana deals with a looming sunset on its Medicaid expansion program is expected to be the main debate in this year’s legislative session. The program covers about 95,000 people in the state who earn up to 138 percent of the federal poverty level, or $15,418 a year for an individual and $26,347 for a family of three.
The Legislature passed expansion, which is a part of the Affordable Care Act, in 2015 in a bill also carried by Buttrey called the Montana Health and Economic Livelihood Partnership (HELP) Act. Lawmakers built in an expiration date of June 2019, saying the sunset was intended to give this year’s Legislature a chance to assess the program. Democrats have proposed a "clean" lift of the sunset, meaning the program would continue as-is without any change.
Medicaid expansion costs the state about $57.4 million a year, though costs are offset by about $28.4 million in savings. The savings come from switching people from regular Medicaid to the expansion plan, which the federal government pays for at a higher rate.
Among the ideas discussed in Buttrey's draft bill is the "community engagement" provision. The requirement could be met through 80 hours of work a month. For those who can't work, there are options like participation in unemployment insurance by seeking a job, part-time university enrollment, training approved by the Department of Labor, substance use disorder treatment, volunteering, behavioral treatment or counseling and participation in correctional programs.
Buttrey said the hour requirement is still being fine-tuned, along with the exemptions.
"We certainly don't want to put an hour requirement that is punitive," Buttrey said. "I'm not trying to do something that's going to cause enrollment numbers to drastically change."
There could also be exceptions for those who are full-time caregivers for dependent children and elders, full-time students and more. That's all still being decided, Buttrey said.
Buttrey said he wants state agencies such as the Department of Revenue, Department of Labor and Industry and Department of Justice, to be able to share data with the state Department of Public Health and Human Services to determine eligibility. He said he'd like to see that work done with existing employees and that the data he wants to use should already be collected.
"We expect the state to be able to implement practices which they should already have," Buttrey said. "The idea is not to have a whole bunch of new folks added."
The draft also has a grant program that would expand the existing HELP-Link program, a voluntary workforce program administered by the state Department of Labor and Industry. The program has been praised as successful and Montana has seen an increase in workforce participation among those eligible for expansion coverage, though there's not a definitive link tying that to the program.
Buttrey wants to expand HELP-Link by offering grants for private employers that hire people going through the program.
The draft would levy a fee on hospital revenue from outpatient services, as well as expand an insurance premium tax to all health insurance companies to generate money to pay for the state's share of Medicaid expansion. Another proposal in the draft is to increase premiums, which are already paid by some covered under the program, by 1 percent after two years of coverage, capped at 5 percent.
The bill draft also would charge a new fee on 501D corporations to help pay for the program. That includes groups like the Hutterite communities that group their assets. Buttrey said the original HELP Act did not intend to cover those groups and doesn't want to single out Hutterites, but they fall into what's proposed in the bill.
The draft bill also includes the idea of including land ownership when looking at a person's assets to determine if they are eligible for coverage, but Buttrey said that's still, like the rest of the bill, open to change.
"Ultimately if we're going to allow taxpayer money to be used, we do have some fiduciary responsibility," Buttrey said. "I don't think we've done a really good job of making sure the state has accounted for taxpayer money being spent," Buttrey said.