Montana Gov. Steve Bullock met with Missoula health providers at Partnership Health Center June 18 to tout Medicaid expansion's role in Montana's response to the coronavirus pandemic. Credit: Kathryn Houghton / MTFP

In 2019, Montana lawmakers passed Medicaid expansion, building in new work and “community engagement” requirements for eligibility. Those requirements were scheduled to go into effect this summer. In the interim, a pandemic has upended both the statewide economy and the employment status and prospects of thousands of Montanans.

Enrollment in the health coverage geared for Montana’s low-income adults has increased for the first time in more than a year. State officials predict that uptick will likely continue as impacts of the COVID-19 pandemic play out. 

In May, Montana’s Medicaid expansion covered 82,174 people — roughly 1,700 more than the month before. That’s the first time enrollment went up since February of last year. 

Similar shifts are happening across the country as millions of people lose their jobs — and their work-based health plans — during efforts to slow the spread of the disease. 

“People living in Medicaid expansion states like Montana may be in a much better position to weather this pandemic than those living in the 14 states that didn’t opt to take up expansion,” Montana Gov. Steve Bullock said during a roundtable with Missoula health providers last week.  

The expansion, which Montana lawmakers first approved in 2015, widened who qualified for the government coverage. That dropped the state’s uninsured rate, meaning more people got access to pre-emergency care and Montana health care providers got a more stable reimbursement regime. 

Dr. James Quirk, chief medical officer at Partnership Health Center in Missoula, said the crisis demonstrates that access to health care is essential. Patients covered by Medicaid have access to COVID-19 testing and related treatment. 

“If we’re all really lucky, they will be able to get a vaccine that’s going to help us get through this without worrying about the cost of getting the vaccine,” Quirk said. 

Dr. Benjamin Sommers, a health economist with Harvard University’s T.H. Chan School of Public Health, said there will likely be widening disparities in health coverage and closures of rural hospitals in states that didn’t expand Medicaid. 

Sommers said states with expansion have an immediate bonus: a bigger pipeline to federal cash. 

The cost of delivering Medicaid coverage is split between states and the federal government. With traditional Medicaid, states can be on the hook for as much as 50% of the program’s cost. With expansion, the federal government covers 90% of the tab.  

The federal government has lots of ways to send money into states during a crisis, but Sommers said it’s hard to predict where that money goes and how long it lasts. 

“Medicaid expansion is a ready way to pump money right into those hospitals, right into those families who have lost jobs, and helping state budgets as well,” Sommers said. 

But there are rules currently in limbo that could change things in Montana. 

Bullock signed the latest version of the state’s expansion into law last year. That required “able-bodied” adults enrolled in Montana’s Medicaid expansion to work, volunteer or train for a job at least 80 hours a month. 

“In times of high unemployment, those kinds of work requirements just get harder and harder and potentially set up a program for failure when it’s most needed.”

Carroll College political scientist Jeremy Johnson

But those community engagement requirements in the state law still need approval from the U.S. Centers for Medicare and Medicaid Services. Montana, which submitted its request to CMS last August, is still waiting on a decision. 

The requirements were a compromise to maintain Montana’s expansion. Republican lawmakers said they wanted more rules to ensure that people don’t rely on the coverage long-term. Democrats pushed back, but failed to secure enough support to continue the expansion without the new requirements. 

Jeremy Johnson, a political scientist with Carroll College in Helena, said it’s not clear that the rules would work well even in the best of economic times, never mind the current economic landscape. 

“In times of high unemployment, those kinds of work requirements just get harder and harder and potentially set up a program for failure when it’s most needed,” Johnson said. 

Joan Alker, a research professor at the Georgetown University McCourt School of Public Policy, said Medicaid work requirements in other states have shown the rules don’t promote higher employment, but do cut people from coverage. She said even people who meet the requirements can still lose coverage because of reporting hoops. 

After an Arkansas experiment with Medicaid work requirements, the state reported more than 18,000 people dropped from the rolls. 

“The pandemic underscores the cruelty of this policy, because it could take away somebody’s health insurance at a time when we have historic levels of unemployment, and it’s more important than ever for people to have health insurance,” Alker said. 

So far, courts have blocked four states from implementing Medicaid work requirements. The latest instance came earlier this year, when a federal appeals court ruled that Arkansas’ work requirements exceeded the Medicaid program’s purpose: to deliver health coverage. 

Nonetheless, CMS has continued to review similar requests. 

As of June 17, 10 states were awaiting approval for Medicaid work requirements, according to the Kaiser Family Foundation. 

In response to a request for an interview about the timeline of Montana’s request, a CMS spokesperson said in an emailed statement that the agency is in ongoing discussions with Montana, but “does not comment on specifics of those discussions.”

“CMS is required to review each state’s proposal on its own merits and consider whether the proposed waivers and/or expenditure authorities are consistent with federal policies,” the spokesperson said. 

In response to a question about what impact Montana’s requirements could have during the pandemic, Bullock said during the roundtable last week that he doesn’t think the rules would have severed people from the coverage. 

He said Montana’s new rules came with “some sidelines around them, constraints around them.” For example, students, people who are full-time caretakers, and people who live in areas designated as high-poverty don’t fall under the work requirement. 

Bullock also said the government adjusted other policies, like increasing unemployment benefits, during the crisis, and could have made similar COVID-specific tweaks to the expansion.  

For now, as part of a national declaration of emergency in response to the pandemic, no one can be disenrolled from Medicaid. But it’s uncertain how long that prohibition will last.   

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Marie Matthews, the state’s Medicaid and health services branch manager, said she’s thankful the state’s new requirements aren’t in place during the current crisis. 

She said that while lawmakers defined community engagement in a variety of ways, “I don’t think they would overcome the difficulty of community engagement reporting requirements during the recession.” 

“If folks are losing their employment, voluntary organizations are experiencing the same sort of crunches, and is that the point in time to decide whether to go back to school and weigh the expense?” Matthews said. 

CMS could approve parts of Montana’s request, or none of it. Matthews said if it’s the latter, the state’s Medicaid expansion will continue much in its current state, with eligibility based solely on need. 

If it’s the former, the state will have to decide whether, and how, to enforce qualifying work requirements during a pandemic-induced economic crunch. 

Katheryn Houghton

Freelance reporter Katheryn Houghton is a former city government and health reporter for the Bozeman Daily Chronicle.