How Ending Premiums Could Threaten Medicaid Expansion in Montana
Dan Gorenstein and Andrea Perdomo – Compromise
Montana Republican State Rep. Ed Buttrey played a key role in expanding the state’s Medicaid program under the Affordable Care Act.
Now, he fears that a change in policy from the Biden administration could, within a few years, mean the end of an expansion that currently provides more than 100,000 low-income Montanese with access to health insurance.
“I’m very, very worried about the risk of us losing the program,” Buttrey said.
Buttrey’s concern revolves around a letter Montana got the Centers for Medicare and Medicaid Services late last year saying that by the end of 2022 the state must stop charging monthly premiums to people on Medicaid. Arkansas received a letter.
Montana is one of 38 states and Washington, D.C., that allows childless adults up to 133% of the federal poverty level to enroll in Medicaid, the joint state-federal program that provides insurance disease to nearly 90 million people, mostly low-income, across the country. .
As part of this expansion, five states – Montana, Arkansas, IndianaIowa and Michigan — received special permission from the Obama administration to charge people a monthly Medicaid fee, which is normally prohibited by federal law.
Conservative lawmakers in those states argued that making people pay the premiums would help prepare beneficiaries to buy private insurance after leaving the program and give them “skin in the game,” the popular but contested idea that if people have to spend more of their own money on health care, they will be more informed consumers.
The Obama administration embraced the idea of the bounties, in part to entice reluctant red 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 displaying premiums makes it more difficult to access coverage.
While many are celebrating the administration’s decision to cut premiums, leaders like Buttrey in conservative states are frustrated.
“It’s just incredible to me that the Biden administration is deciding not to allow bounties at all,” Buttrey said. “This has always been one of the cornerstones of our Medicaid expansion program in Montana.”
Medicaid expansion in Montana
Buttrey spent day after day in 2015 meeting with the then governor. Steve Bullock, a Democrat, trying to hammer out a Medicaid expansion deal that could win support from skeptical Republicans in the state legislature.
“I left the room several times and hung up on the Governor,” Buttrey said. “It was just a very emotional and passionate process because we all wanted to do something.”
For Buttrey and his fellow Tories, bonuses had to be part of the equation.
“We wanted there to be personal accountability and that included having rewards for healthy behavior, having a good pathway out of poverty. We needed people to be able to pay bounties, to have their skin in the game,” Buttrey said.
Bullock vehemently opposed charging Medicaid beneficiaries for coverage, but he eventually agreed. The premium was set at 2% of household income. Some groups — including the sickest, poorest, and those living in areas without many providers — were exempt, and only people with incomes between 100% and 138% of the federal poverty level could be excluded for no -payment.
More than 100,000 people — about 10 percent of Montana’s population — are currently enrolled in the Medicaid expansion. A University of Montana 2021 report Medicaid expansion in Montana has helped more people get medical care, created thousands of new jobs, and generated about $650 million in economic activity in the state each year. He also found that 40% 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 were kicked off Medicaid rolls for not paying their premiums, or 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 study 2020 which included Montana and found that the premiums were likely keeping enrollment down and preventing people from staying on 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 and low income beneficiaries.
“When you have a dozen studies all pointing in the same direction, it becomes much harder to say that premiums won’t have any effect on enrollment,” said Kate Bradley, senior researcher at the organization of Mathematica policy research that helped lead the 2020 study.
The Trump administration has approved three more states – Arizona, Georgia and Wisconsin – to charge bonuses, although Arizona and Georgia never implemented them. Arizona removed bonuses from its plan in 2020 and the Biden administration took of At the same time, Georgian authorities asked Montana and Arkansas to end 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 which other states are currently allowed to charge bonuses, but a spokesperson for CMS said the agency would consider the same research when reassessing those bonus plans. States in the years to come.
Buttrey said he didn’t like seeing anyone lose their coverage, but overall he feels the program has achieved its goals of improving the state’s health and economy. And he fears that without the ability to charge premiums, Montana conservatives will balk at reviving Medicaid expansion in 2025, when the deal Buttrey helped orchestrate expires.
“I’ve personally had a lot of interactions with people whose lives have been saved because they got access to health care or got access to addiction treatment,” Buttrey said. “It’s going to be hard to stare these people in the face if I don’t agree to move the program forward one way or another, but I don’t know. I am ripped.”
This story is from the Health Policy Podcast Compromisepartner of Public media on side effects. Dan Gorenstein is the editor of Tradeoffs and Andrea Perdomo is a reporter/producer for the show, which aired a version of this story the 17th of March.