Health and human services at the legislative halftime

Health and human services debates have spread to nearly every committee room and hallway of the state Capitol during the first half of the 68th Legislature. 

There’s good reason for the saturation. Health care is one of Montana’s biggest industries, and encompasses a host of ethical debates that hold public attention — abortion, vaccines and health care access, to name a few. Some of the defining topics debated so far include the future of Montana’s Medicaid programs, strains on providers and the health care workforce, and ongoing battles over reproductive rights as the map for abortion access shifts nationwide. 

Human services issues — particularly reforming Montana’s child welfare system to decrease foster care involvement — have also consumed hours of deliberation this session. Lawmakers have shown an intense interest in family unification, child safety and parental rights — all themes that are playing out in a surge of policy proposals.

Some of the bills addressing these and other issues passed between the House and Senate earlier this session. Other major proposals were held up until the last two weeks, when policy making went into hyperdrive before the transmittal deadline. Bills with attached fiscal notes don’t face the same legislative cliff as those without — some legislation will remain in its chamber of origin to be discussed by an appropriations committee — but still cleared a major hurdle by gaining initial approval from a majority of lawmakers in their chamber. 

Here are some of the most significant policies that survived and failed in recent weeks.  

MEDICAID, NURSING HOMES AND COST CAPS

• ✅ House Bill 649, a Democrat-carried bill to fund Medicaid provider rates at the standards identified by a 2022 state-commissioned study by the consulting firm Guidehouse and account for annual inflation, passed second reading in the House by a broad margin, 65-35. Sponsor Rep. Mary Caferro, D-Helena, framed the bill as an investment in the state’s largest industry, in rural and urban communities, and in an essential workforce caring for some of Montana’s most vulnerable citizens. It will now be shuttled to the House Appropriations Committee for further debate and approval. 
• ✅ Senate Bill 296 creates a Medicaid funding framework to help keep nursing homes and senior living facilities afloat long-term, including an at least 3% annual increase to account for inflation. The bill, sponsored by Sen. Becky Beard, R-Elliston, has the backing of nursing home operators trying to stave off future closures. It passed an initial vote in the Senate 37-13 Friday and has been referred to the Senate Finance and Claims Committee for further debate.
• ❌ Senate Bill 465 proposed to implement work requirements for some Medicaid expansion recipients by December 2023. The bill, brought by Sen. Jeremy Trebas, R-Great Falls, conflicts with a federal prohibition on work conditions and would require Montana to reconsider its expansion program, which covers health care for about 120,000 people. Legislative staff and the state health department warned the bill could conflict with the supremacy clause of the U.S. Constitution and cost Montana up to $760 million annually to shoulder the federal part of the program. The bill narrowly failed second reading on the Senate floor Thursday, 24-26. 
• ❌ House Bill 609 sought to reimplement 12 months of continuous coverage for Medicaid recipients. That standard was a feature of the state’s Medicaid expansion program until a Republican-supported change in the state budget went into effect in December 2021. The bill to reverse that decision, sponsored by Rep. SJ Howell, D-Missoula, had enough Republican support to pass out of the House Human Services Committee last week, but died on the House floor Thursday, 37-63.
• ✅ Senate Bill 364 would limit hospital charges to 250% of the reimbursement cost of Medicare, typically on par with the cost of service. Sen. Greg Hertz, R-Polson, the sponsor of the bill, argued it would result in lower charges to third party insurers and, therefore, lower costs for employers who offer health care insurance. Hospital industry representatives testified against the bill during its committee hearing, telling lawmakers it would hamstring budgets, undercut providers’ ability to offer services, and fail to actually lower costs for employers and patients — all arguments Hertz rejected. The policy passed the Senate on Thursday in a 27-21 vote, with some Democrats joining Republicans to vote in favor. 

ABORTION

Republicans pushed through a slate of abortion restrictions in the first 45 days of the session, a policy priority that picked up steam as the transmittal deadline approached. Democrats proposed several alternative bills to enshrine Montana’s current legal protections for abortion access in state law and, in some cases, expand reproductive rights — all of those policies were rejected in prior weeks. 

• ✅ House Bill 721, introduced by House Speaker Matt Regier, R-Kalispell, would effectively ban abortions in the second trimester of pregnancy by outlawing “dismemberment abortions,” a non-medical term broadly defined in the bill text to encapsulate dilation and evacuation procedures, the safest and most common method for terminating a pregnancy after 15 weeks. The bill, opposed by reproductive rights groups and endorsed by anti-abortion advocates, passed the House along party lines Friday, 67-31. 

• ✅ House Bill 575 prohibits the abortion of a viable fetus, which the measure defines as any time later than 24 weeks of gestation, unless necessary to save the mother’s life. The bill, sponsored by Rep. Lola Sheldon-Galloway, R-Great Falls, was opposed by Montana medical providers who stressed that complications can arise after that point in pregnancy, including failure to develop vital organs, that force families to make difficult decisions about whether to terminate a pregnancy. The bill passed the House Thursday 68-31. 
• ✅ House Bill 544 requires pre-authorization for Medicaid-eligible abortions as a way to bring more state oversight to abortions that providers define as “medically necessary.” The state’s Medicaid program, not including federal dollars, has been required to cover abortions that meet that medical necessity standard for people with public insurance since a 1995 state court ruling. The bill, sponsored by Rep. Jane Gillette, R-Bozeman, echoes a state health department rule revision that is currently pending. HB 544 passed an initial House vote Thursday along party lines, 69-31, and has been referred to the House Appropriations Committee.
• ✅ House Bill 786 would increase reporting requirements for health care providers who prescribe abortion medication. Those providers would have to administer a form to patients with information about adverse side effects and also file additional reports with the state health department. The bill, sponsored by Rep. Lola Sheldon-Galloway, R-Great Falls, passed the House Friday with two dissenting Republican votes, 65-33. 
• ✅ House Bill 625, sponsored by Rep. Kerri Seekins-Crowe, R-Billings, would require health care providers to render reasonable medical aid to an infant born alive at any gestational age, regardless of viability, while allowing parents to decline medical interventions if those procedures “will do no more than temporarily prolong the act of dying when death is imminent.” The bill, which defines “born alive” as an infant who “breathes, has a beating heart, or has definite movement of voluntary muscles,” is a similar policy to LR-131, which voters rejected in November. It passed the House Friday on a nearly party-line vote, 66-32.

CHILD WELFARE AND FAMILY LAW

Reforms to Montana’s child welfare system have been top of mind for Republican and Democratic lawmakers this session, with several bipartisan proposals advancing between the House and Senate in January and February. Lawmakers continued to move several more proposals before the transmittal deadline, with some veering into more controversial territory and failing to pass muster. 

• ✅ House Bill 513, sponsored by Rep. Jennifer Carlson, R-Manhattan, would require child protection specialists and court systems to document and weigh the risks of harm that stem from removing children from their families against the potential consequences of leaving them in an abusive or neglectful environment. The bill underwent several rounds of revisions in committee, ultimately picking up bipartisan support from most of the Democratic caucus. It passed the House floor Wednesday 92-6.
• ✅ House Bill 317, the Montana Indian Child Welfare Act, passed the House last Tuesday, 64-35. Bill sponsor Rep. Jonathan Windy Boy, D-Box Elder, has advocated for HB 317 as another layer of protection for tribal sovereignty and preservation of Native American families and heritage throughout the child removal, foster care and adoption process in the event the federal Indian Child Welfare Act is weakened or curtailed by future court rulings. It will now be considered by the Senate. 
• ✅ Senate Bill 250, sponsored by Sen. Theresa Manzella, R-Hamilton, would change court procedures for determining child custody in divorce and separation cases. The bill, motivated in part by federal reforms known as Kayden’s Law, aims to prohibit forced reunification with an abusive or unsafe parent under the “parental alienation” theory by requiring expert witnesses to have clinical experience in domestic abuse cases. The bill is championed by parents’ groups, but opposed by some Montana domestic violence advocacy coalitions because of the restriction on expert witness testimony they say would undermine court proceedings. 

SB 250 failed to pass an initial vote in the Senate Monday on a 25-25 tie, but was reconsidered the following day with the consent of 29 lawmakers, with 21 Democrats and some Republicans opposed. The bill was later amended and approved March 1 on a 29-21 vote and passed to the Senate Finance and Claims Committee for further consideration. 

• ❌ House Bill 762, a bill to require courts to use licensed health care providers to evaluate domestic violence allegations in parenting plan cases, failed to pass the House floor Thursday on a 43-57 vote, with a mix of Republicans and Democrats voting no. Rep. Caleb Hinkle, R-Belgrade, in a high-volume and pointed closing, alluded to unqualified consultants making “biased decisions” in complicated family court proceedings. Opponents stressed the shortage of qualified health care professionals to fill those rolls and the risk of hamstringing an already overburdened court system.
• ✅ Senate Bill 180 would change the job descriptions of Court Appointed Special Advocates and make the appointment of those volunteers optional during family court proceedings. The bill, sponsored by Sen. Dennis Lenz, R-Billings, was opposed by CASAs, but supported by other child welfare reform advocates during a January hearing. It passed the Senate floor Monday 28-22, with six Republicans and all Democrats opposed.
• ✅ House Bill 482, sponsored by Rep. Jane Gillette, R-Bozeman, would create a grant program administered by the Board of Higher Education to help create wraparound scholastic and residential support services for youth who age out of foster care and enroll in a community or tribal college, public university or vocational program. Any institution receiving a grant would develop a program that includes year-round room and board on campus as well as meal plans, in addition to other benefits. The bill passed an initial vote on the House floor 96-4 and has been referred to the House Appropriations Committee. 

LOOKING AHEAD

Lawmakers, state agencies and health and human services stakeholders have their work cut out for them in the next 45 days of the Legislature. 

On the health care front, lawmakers and medical industry groups will be fighting for competing interests in the health department budget and finalizing Medicaid rates. Advocacy groups will be feuding over abortion restrictions, most of which await the judgment of lawmakers in the Senate. And legislators, the state health department and representatives of the court system will continue to hash out proposed changes to child welfare proceedings, in part by coordinating multiple bills revising the same sections of current law.