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The debate over extending Medicaid expansion in Montana took over the state Capitol on Saturday, with an all-day hearing on two bills presenting dramatically different proposals to continue the program.

A rally filled the building's rotunda, with participants calling for the continuation of the program that covers more than 96,000 Montanans without the addition of work requirements, their cries reaching the room where lawmakers heard debate on the bills a floor above.

Continuing Medicaid expansion is expected to be the main — and most contentious — issue of the Legislature this session. The program covers those who earn up to 138 percent of the federal poverty level and was passed in 2015 with a sunset date of this summer unless lawmakers act. In April, the 2019 federal poverty level will be $17,236 for an individual and $29,435 for a family of three.

While there’s general agreement over continuing the program, lawmakers are heading into a battle over the best way to accomplish that.

As both bills had their first hearing, dozens of people traveled from across Montana to support and oppose both the individual bills and voice their opinions on whether Medicaid expansion has been good for the state. Many more looked on from the old State Supreme Court chambers, spilling out into the hallway and watching the hearing on large projection screens in meeting rooms on the first floor of the building.

Rep. Ed Buttrey, a Republican from Great Falls who carried the original bill that expanded Medicaid four years ago, is taking another crack at the program this session. His bill proposes to add work requirements, which he calls community engagement, and additional asset and means testing. It also creates a grant program for businesses that hire people covered by expansion.

The Democrats’ version of the bill is House Bill 425 from Rep. Mary Caferro, a Democrat from Helena. Her proposal continues the program much in its current form, but with $6 million more for a voluntary workforce program that was also created in 2015.

Both bills increase a fee on hospitals to pay for the state's share of the program. Buttrey's House Bill 658 would also implement additional fees.

Many who testified raised concerns over the work requirements in Buttrey's bill, which would require people to work or volunteer 80 hours a month unless they fall under exemptions in the bill. Similar requirements in Arkansas caused thousands there to lose coverage.

Studies done on Buttrey's bill have also estimated people would lose coverage here — the most recent projecting half of those covered would be removed from the program. Buttrey said last week and again Saturday there are still changes coming to the bill, though he didn't say what, that would address those concerns.

Kate Clyatt, who works on ranches outside Helena, said the seasonal nature of her job could make it difficult to meet the work hours requirement. She also said the places she's employed have poor internet and cellphone access, which would make reporting difficult.

"I don't want to lose my coverage because my work schedule does not conform to a typical 9-5 job," Clyatt said.

Jess Rhoades, the health policy adviser for Gov. Steve Bullock, a Democrat, said Montana has a successful voluntary workforce development program in place and adding requirements would not increase long-term employment.

During the period Montana has implemented the voluntary program, workforce participation in Montana among the population eligible for expansion coverage has increased 8.5 percent while it dropped 2.5 percent nationally among the same group.

Others raised concerns over legal challenges to work requirements in other states.

Most who spoke in support of Buttrey's bill said they think Medicaid expansion has been successful for Montana and they want to see it continue, but with additional requirements to make sure the people who need coverage the most get it.

Rep. Nancy Ballance is a Republican from Hamilton who long opposed expanding the program and voted against in in 2013 and 2015. On Saturday Ballance said she now believes expansion has helped people who were not able to access care before improve their lives.

She said if Montana wants to end the cycles of addiction, mental health issues, chronic conditions and other health care needs, the GOP need to support Buttrey's bill. 

"I can no longer ignore that, and I cannot let Republican ideology stand in the way of what I know is doing the right thing," Ballance said.

Members of the so-called Solutions Caucus, Republicans who have indicated they could support expansion with additional requirements on the program, have already signed onto Buttrey's bill. That includes 18 Republicans in the House and nine in the Senate. All Democrats in the House and Senate, who are the minority party in the Legislature, support Caferro's bill.

Hospitals, health care providers, insurers and other groups also spoke in support of Buttrey's bill, saying they wanted to see Medicaid expansion continue because it's been good for health outcomes and the financial stability of rural hospitals, and has created stability in the health insurance industry.

Those who back Caferro’s bill as the best way to extend the program shared personal stories of health issues they were able to treat because they had coverage through Medicaid expansion, some saying coverage was the difference between life and death.

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Lawmakers also heard from those in Native American communities both on and off reservations around the state. Medicaid expansion has had an outsize effect in those communities. More people having insurance coverage has reduced the burden on Indian Health Services, which freed up money for that program. IHS has moved from paying for only life-and-limb needs to providing preventive services.

"As a tribal health care facility, this funding is something that if we lose expanded Medicaid, we're back to those types of times when we're having to tell people we can't pay for this test that might determine whether there's a disease or not," said Jessica Windy Boy, who runs the tribal health center on the Rocky Boy's Reservation in northcentral Montana. "The importance of this bill is serious. It's human lives."

Some who spoke generally opposed Medicaid expansion continuing at all. That included a handful of Republican lawmakers who said the federal government can’t continue to pay for programs under a growing national debt, and questioned the stability of the program. Others said money the state puts toward expansion could be spent elsewhere.

"Do we love our country if we keep putting it farther in debt? Do we love our state if we're not keeping our state solvent?" said Sen. David Howard, a Republican from Park City.

Some opponents to expansion said they look at budget cuts put into place after the 2017 legislative session that cut provider rates for Medicaid services and were frustrated that services for those on traditional Medicaid were reduced.

They argued if the state didn't spend money on Medicaid expansion, the funding could have helped traditional Medicaid programs. 

"You cut services (and funding) for service providers for disabled people," said John Harwood, a man from Joliet who said his disabled son was covered by traditional Medicaid before he passed away. 

Many opponents held up as an example the November 2018 election, which saw voters shoot down a proposal to lift the sunset on Medicaid expansion and pay for the program by increasing the state’s tobacco tax. They said Montanans had already weighed in on the issues.

"For us to tell the people that elected us and sent us here, 'Your vote does not count and you are not intelligent enough or … capable enough to make a decision' is a slap in the face," Rep. Brad Tschida, a Republican from Missoula, said.

Tobacco companies spent more than $17.2 million to defeat that initiative, and $26.1 million was spent total, making it the most expensive ballot initiative in state history.

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State Bureau reporter for The Independent Record.

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