How ending premiums could threaten Medicaid expansion in Montana

HELENA, Mon. — Montana Republican State Representative Ed Buttrey was a key player in expanding the state’s Medicaid program under the Affordable Care Act.

Now, he worries that a policy change by the Biden administration could, in a few years, spell the end of an expansion that currently provides more than 100,000 low-income Montanans access to health insurance.

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“I’m very, very worried about the risk that we lose the show,” Buttrey said.

Buttrey’s concern centers on a letter Montana received from the Centers for Medicare & Medicaid Services late last year that by the end of 2022, the state must stop charging monthly premiums to people on Medicaid. Arkansas received a similar letter.

Montana is one of 38 states and Washington, DC, that allows childless adults earning up to 133 percent of the federal poverty level to enroll in Medicaid, the joint federal and state program that provides health insurance to nearly 90 million , mostly low-income people across the country. .

As part of that expansion, five states: Montana, Arkansas, IndianaIowa and Michigan — received special permission from the Obama administration to charge people monthly Medicaid fees, something normally prohibited by federal law.

Conservative lawmakers in those states argued that making people pay premiums would help prepare beneficiaries to buy private insurance after they left the program and give them “flesh in the game,” the popular but controversial idea that if people have to spend more of their own money on health care, they will be smarter consumers.

The Obama administration agreed to the premium idea, in part to spur reluctant Republican states to expand their Medicaid programs under the president’s landmark health care law. But the Biden administration is changing course thanks to a growing evidence base Showing premiums makes it more difficult for people to access coverage.

While many celebrate the administration’s decision to lower premiums, leaders like Buttrey in conservative states they are frustrated.

“I’m just shocked that the Biden administration decides they’re not going to allow premiums at all,” Buttrey said. “That has always been one of the cornerstones of our Medicaid expansion program in Montana.”

Expanding Medicaid in Montana

Buttrey spent day after day in 2015 meeting with the then-governor. Steve Bullock, a Democrat, trying to forge a Medicaid expansion deal that could win the support of skeptical Republicans in the state legislature.

“I walked out of the room multiple times and hung up on the governor,” Buttrey said. “It was a very emotional and passionate process because we all wanted to do something.”

For Buttrey and his conservative colleagues, bonuses had to be part of the equation.

“We wanted there to be personal responsibility and that included having rewards for healthy behavior, having a good path out of poverty. We needed people who could pay the premiums, who would play the game,” Buttrey said.

Bullock vehemently opposed charging Medicaid recipients for coverage, but ultimately agreed. The premium was set at 2 percent of household income. certain groups — including the sickest, the poorest and those who lived in areas without many providers — were exempt, and only people with incomes between 100 percent and 138 percent of the federal poverty level could be kicked out for nonpayment.

More than 100,000 people, about 10 percent of Montana’s population, are currently enrolled in expanded Medicaid. A University of Montana 2021 report found that the expansion of Medicaid in Montana helped more people obtain health care, created thousands of new jobs, and generated about $650 million in economic activity in the state each year. He also found that 40 percent of the $80 million the state spends annually on expansion is offset by lower health care costs and increased economic activity.

At the same time, state records show that at least 7,000 people have been kicked off Medicaid rolls for not paying their premiums, about 200 to 300 people each month.

“That’s a pretty significant percentage,” said Heather O’Loughlin, co-director of the nonpartisan Montana Budget and Policy Center.

the road ahead

In its letter telling Montana to phase out its premiums, CMS cited several studies on the impact of Medicaid premiums, including a studio 2020 that included Montana and found that premiums likely kept enrollment lower and kept people from staying in the program as long, even people who were exempt from paying.

The CMS letter also cited research showing that premiums can exacerbate health disparities by disproportionately affecting Black Y low income beneficiaries.

“When you have a dozen studies all pointing in the same direction, it becomes much more difficult to argue that premiums will have no effect on enrollment,” said Kate Bradley, a senior fellow at the policy research organization Mathematica, who helped to lead the 2020 study.

The Trump administration approved three more states, Arizona, Georgia and Wisconsin, to charge premiums, though Arizona and Georgia never implemented them. Arizona eliminated premiums from its plan in 2020 and the Biden administration he retired The Georgia authority at the same time told Montana and Arkansas to scale back their programs. Wisconsin, which has not expanded Medicaid, briefly charged premiums before going on hiatus due to COVID.

The Biden administration has yet to take action on the other states that are currently allowed to charge premiums, but a CMS spokesman said the agency will consider the same investigation when reevaluating those states’ premium plans in coming years.

Buttrey said he doesn’t like anyone losing coverage, but overall he feels the program has met its goals of improving the state’s health and economy. And he worries that without the ability to collect premiums, conservatives in Montana might refuse to revive Medicaid expansion in 2025, when the deal Buttrey helped orchestrate expires.

“Personally, I have had many interactions with people whose lives have been saved because they have had access to healthcare or addiction treatment,” Buttrey said. “It’s going to be hard to look those people in the face if I don’t support the show moving forward in some way, but I don’t know. I am torn.

This story comes from the health policy podcast. offsetspartner of Side Effects Public Media. Dan Gorenstein is executive editor of Tradeoffs, and Andrea Perdomo is a reporter/producer for the show, which aired a version of this story on March 17.

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