HAVRE — Andrea Melle’s home sits high on a hill overlooking Havre. Forty-six steps lead from the sidewalk to her front door.
Inside, Melle’s son, 19-year-old Drew, unwinds from school with YouTube. Her daughter, 21-year-old Kerrie, curls up on a comfy chair and chats with a visiting reporter about her part-time job shelving books at the local library. Kerrie has always wanted to be a librarian, but she’s unable to work more than a few hours at a time or live on her own. In the background, Drew compulsively grunts and yelps, his eyes still fixed on the computer screen.
Drew and Kerrie are Melle’s only children, and they’re both autistic. Melle, 51, cares for them full-time. That leaves her only enough time to work as a cleaner at her local church and bring home a meager monthly income.
For Melle, Medicaid expansion has been a source of solace.
“I’m going to be here as long as possible. I made a deal with God,” she says with a laugh. “You never know when something might happen, and if I’m not healthy I can’t take care of them.”
Kerrie and Drew receive health coverage through Social Security due to their disabilities. Melle found out she qualified for Medicaid while going through a divorce in 2015.
“I got onto the Obamacare website, and it said ‘you qualify for your state’s Medicaid expansion,’” she said. “It was a blessing. I was like, ‘Oh, thank you Lord.’”
Melle had insurance under her ex-husband’s plan, but she spent much of her adult life sacrificing her own health to take care of her family. She used to be 100 pounds overweight. She has a family history of glaucoma and diabetes, but she never went to the doctor unless it was an emergency.
Under Medicaid, Melle has become more proactive about her health. She schedules regular checkups at the clinic in Havre, which the program covers 100 percent.
Luckily, Melle’s home is paid off, too. She fought to keep the house during the divorce, and it provides stability for her children, who are highly sensitive and need a steady routine to thrive. Moving to a bigger city with more resources is out of the question.
Drew and Kerrie’s father moved to Arizona last October. They have limited contact with him, Kerrie said. Child-support payments will end once Drew graduates from Havre High School in May, since Montana has no law requiring parents to support disabled kids beyond age 19.
“It is what it is,” Melle says.
It’s a phrase she repeats often.
Despite the challenges of mothering and caretaking two disabled adults, Melle is gracious and gregarious. She laughs and jokes with her children. She decorates the walls with their artwork and family photos. She encourages Kerrie to play guitar and sing in the church choir. She occasionally splurges on Scooby-Doo costumes for Drew.
But Melle worries, too.
Montana’s Medicaid expansion law, the HELP Act, went into effect in late 2015. It provides health-care coverage to low-income Montana families and individuals who make less than 138 percent of the federal poverty rate. For a family of three like Melle’s, that limit is just over $29,000 a year.
The HELP Act is set to sunset this summer.
The Montana Legislature is currently embroiled in a debate about whether or how the state’s Medicaid expansion program should continue. Coverage for 96,000 Montanans like Melle hangs in the balance.
Three political factions
Republicans hold a majority in the Legislature, but any Medicaid expansion bill will require the Democratic governor’s signature to become law.
As of this week, only one bill could make it that far: House Bill 658, sponsored by Rep. Ed Buttrey, a Republican from Great Falls. The proposal made its way out of the House Human Services Committee, with multiple amendments, in a late-evening session Tuesday. That doesn’t mean Buttrey’s bill is a sure thing.
HB 658 adds work requirements for Medicaid expansion enrollees, which Buttrey calls “community engagement.” He said that provision is the only way to guarantee Republican support.
“I can’t pass the bill without the community engagement,” Buttrey said in an interview. “Even if all 42 Democrats were to vote for it, I don’t have enough Republicans to pass it.”
Those requirements, however, could make the bill a tough sell to Democrats.
Democrats initially supported House Bill 425, sponsored by Rep. Mary Caferro, D-Helena. That legislation would have left the existing Medicaid expansion program largely intact. Caferro’s bill drew nearly 100 supporters from around Montana during a committee hearing on March 16.
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Once it came time for the committee to vote, however, Republicans modified the bill with amendments adding work requirements and another sunset date. Those changes transformed Caferro’s bill to the point that it became unpalatable to supporters. Democrats on the committee ended up voting to table their own bill.
“[HB] 425 started out as a great bill. It was a pure form of Medicaid expansion that Montanans need,” said Rep. Gordon Pierson, D-Deer Lodge, during last week’s hearing. “I can’t support it now, I really can’t. It saddens me to say that.”
In a twist, HB 658 made it out of committee only because Democrats reluctantly signed on. With Caferro’s bill likely dead (it also failed a blast motion on the House floor), Buttrey’s proposal appears to be the best hope for Medicaid expansion to continue.
But Buttrey can’t seem to get the Republican support he needs, despite the work requirements. During the committee hearing, only three of eight Republicans, including Buttrey, voted to support HB 658.
Buttrey is part of a small group of GOP lawmakers who brand themselves the “Solutions Caucus” and occasionally deviate from the party line. At times, they compromise with Democrats to pass legislation. Such compromise is how Buttrey was able to pass the original HELP Act in 2015.
But more hardline Republicans, led by majority leader Brad Tschida, R-Missoula, want Medicaid expansion to sunset.
“The issue really is, in my mind, the increase in taxes that are going to be required to continue Medicaid expansion under its present form,” Tschida said in an interview. “The main thing I heard when I was campaigning, especially in Missoula, is that taxes have just exploded. People, they’re not fatigued, they’re absolutely beaten down by taxes.”
Tschida said last fall’s I-185 ballot initiative is a mandate from the Montana majority. The proposal would have made Medicaid expansion permanent and partially funded it with a tax on cigarettes.
I-185 failed with almost 53 percent of Montana voters saying “no” to the initiative.
Tschida noted that only 17 percent of Montanans smoke, and he takes that to mean voters rejected more than just a tax on tobacco.
(A campaign led by tobacco lobbyists spent millions on a campaign that whipped up fears that additional taxes, on top of the proposed cigarette tax, would be required to fund Medicaid expansion).
Federal funds guarantee 90 percent coverage of the cost of Medicaid expansion, and Montana hospitals have agreed to cover part of the state’s share. Tschida said he has concerns about relying on the federal government money, too.
“It’s really utilizing the federal credit card rather than the state credit card, so it adds to our deficit,” Tschida said.
The federal government spent $399 billion on Medicaid and the Children’s Health Insurance Program in 2018, according to the Tax Policy Center. At the end of 2017, U.S. debt was more than $20 trillion.
“I have kids and grandkids. I’m worried about the sustainability of a [Medicaid] program,” Tschida said. “When it’s no longer financially prudent, what do we do?”
That’s where Solutions Caucus Republicans and what Tschida calls “traditional” Republicans tend to butt heads in Montana.
“Those of us who believe government should be limited and taxes as low as possible have nothing to offer, really,” Tschida said. “We’re not asking for anything in return but to be left alone by government.”
Buttrey, however, said his bill is designed to make low-income Montanans less reliant on government money in the long run. That’s why he wants work requirements — so Medicaid enrollees can improve their financial situations and find jobs that offer private insurance.
“When I wrote the original bill, the intent was to get people up and off of public subsidies and off Medicaid expansion … and that’s still the goal,” Buttrey said.
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He also disagrees with Tschida’s interpretation of I-185’s failure.
“I believe [voters] weren’t saying ‘no’ to Medicaid expansion in general, they were saying ‘no’ without a work requirement or some way to hold people accountable for utilization of the taxpayers’ money,” Buttrey said.
Avoiding a veto
Democratic Gov. Steve Bullock ultimately carries the power of the veto. His office has made no secret about its opposition to Buttrey’s bill. A spokesman for Bullock’s office testified against the bill during the March 16 hearing.
The Governor’s Office of Budget and Program Planning also released a stinging fiscal note that found Buttrey’s bill would kick about half of Montana’s Medicaid expansion enrollees off the program.
The note cites a study commissioned by the Montana Healthcare Foundation and issued by George Washington University on Feb. 13. That study found that 31,000 to 43,000 of those enrollees could lose health coverage under the work requirements Buttrey proposes.
(The Montana Healthcare Foundation is nonpartisan, but the organization supports the continuation of Medicaid expansion.)
The foundation’s report estimates almost a third of Montana’s adult beneficiaries could lose coverage because they live in rural areas with few work opportunities, and about a quarter of those under threat of losing their coverage have dependents with disabilities, the study found.
For Medicaid expansion enrollees that would remain, the fiscal note estimates costs to the state would nearly double per patient under Buttrey’s proposal.
The state would need to hire an additional 85 employees to track Medicaid enrollees and make sure they meet the community engagement mandate, according to the Office of Budget and Program Planning.
Buttrey’s bill requires 80 hours a month of work or volunteer service, although in some cases the requirement can be satisfied with work training, substance abuse treatment, and educational credits.
The work requirements are also subject to certain exemptions, including full-time care-givers for young children and disabled adults. State staff would have to verify those exemptions.
Buttrey disagreed with the governor’s office findings and refused to sign the fiscal note.
“Fiscal notes are political tools,” Buttrey said. “I don’t think it’s accurate.”
Nevertheless, Buttrey added numerous amendments to his bill to address the fiscal note during this week’s committee vote.
Those changes give more flexibility to the Department of Public Health and Human Services in administering the program and tracking work requirements. They also offer additional latitude to Medicaid enrollees who are unable to find work.
If the department notices more than 5 percent of enrollees losing their Medicaid coverage under Buttrey’s bill, the amendments trigger an audit to find out why.
“It’s not designed to cut a ton of people off the program,” Buttrey said. “By the time it’s fully implemented, we’ll nearly be in the 2021 session, so if we do find there are unintended consequences, it will be very easy for the Legislature to act and fix this.”
A revised fiscal note is pending. The bill now awaits a vote on the House floor. Representatives face an April 1 deadline to move the proposal for renewed debate and possible amendment in the Senate.
“I really believe in the program. I think it’s helped a lot of people, it can be made better and I’m going to fight for it,” Buttrey said. “Ideally I’d like it to be bipartisan, where we can get a large number of votes on both sides. But it is what it is.”
Realizing what’s at stake
Melle has watched the debate over Medicaid expansion closely from Havre.
“I’m shocked at how many Republicans don’t even want it, period. That was kind of appalling,” she said. “Health care is not a game to me, and they kind of act like it’s a game.”
Melle hasn’t participated in politics in the past, but advocating for her children has made her more engaged in public policies and processes.
“I never used to be until the last couple years, but then I realized I have to be. I have to fight for myself and my kids’ future,” she says. “I realized how much was at stake.”
Melle has begun to advocate for families in situations like hers. She regularly attends town halls with her representatives. She spoke about her situation with Rep. Caferro, who has since introduced House Bill 726, which would extend child support payments for families with disabled adults. It had its first hearing March 26.
Above all, Melle said, she has especially strong feelings about Medicaid expansion. Even if Buttrey’s bill passes and guarantees her coverage as a caregiver, she worries about others who could be left behind.
“You don’t know what’s going on in our lives, you’re not in our shoes,” Melle says. “We shouldn’t have to worry about health care in America.”
Our reporting on health-care issues is funded in part by a grant from the Montana Healthcare Foundation.