In anticipation of the debate whether to keep Medicaid expansion in Montana, the Montana Healthcare Foundation has released a series of reports it commissioned looking at the impacts of the program on the state’s healthcare, residents and economy.

The annual Medicaid in Montana report has been released annually by the foundation, and this year it highlights a number of key findings throughout the state, including that while the number of people enrolling in the program has decreased — the result of “redetermination” after the COVID-19 emergency — hospitals, including the very small rural ones, have been able to add healthcare services such as orthopedics and behavioral health, an unexpected finding.

The report also found that most of the people covered under Medicaid expansion are in the workforce or a full-time caregiver for a family member. Moreover, the health outcomes and life expectancy have increased, as the average cost per patient decreases over time because the data suggests that healthcare coverage means health issues are addressed earlier and prevented before they become emergency issues.

One other report, commissioned by the Montana Healthcare Foundation and released earlier this month, specifically looked at the economic effects of Medicaid expansion in Montana and was authored by well-known in-state economist Bryce Ward through ABMJ Consulting. That report found that while Medicaid expansion continues to provide access to healthcare, the expansion has accelerated the build-out of Montana’s healthcare system, creating more providers, more jobs and adding as much as $560 million in additional personal income to the economy.

“Medicaid expansion does not impose a fiscal cost on the state,” the report concludes. “Savings generated by expansion coupled with increased revenues attributable to expansion more than offset the state’s share of expansion costs.”

More services added

One of the new findings of the yearly study is that Medicaid expansion in Montana has improved the financial health of many critical-care access hospitals and organizations. The reimbursements meant that not as much revenue had to be diverted to cover those residents without insurance.

The report explains that fewer uninsured residents has translated to other services like orthopedics and physical therapy being offered in smaller settings, often closer to home for rural populations. Many systems also reported adding behavioral health services in a state that has a high rate of suicide.

“Medicaid expansion created a new revenue source for Montana’s critical access hospitals, reducing ‘bad debt’ from uninsured individuals and allowing them to invest in hiring new providers and adding service lines that were previously not accessible in more than urban areas,” the annual Medicaid report concluded.

Ward’s report also backed up those findings.

“Before expansion, uncompensated care (uninsured patients) in Montana was equal to 5% of operating expenses,” the report said. “However, it fell to 2% after expansion. In non-expansion states, uncompensated care remained constant.”

Dr. Aaron Wernham, the CEO of the Montana Healthcare Foundation, said expansion has helped the financial picture in a number of ways. New services become available to all patients, not just Medicaid expansion patients, and those services usually have a higher margin, which means they improve the overall financial health of system.

“Those are services that will be available to everyone, whether they’re on Medicaid or not,” Wernham said.

Wernham said that is backed up by another portion of the reports, which focuses on the new healthcare jobs that have been added since Medicaid expansion.

Ward said that Medicaid expansion added $200 million to $300 million to the healthcare economy.

“For instance, Montana has approximately 50 additional primary care physicians and 20 additional dentists due to Medicaid expansion,” the report said.

“That’s an amazing statistic because we’ve been historically underserved,” Wernham said.

New money from the program is flowing into the state, both reports point out.

“Without Medicaid expansion, these dollars would not have been spent in Montana (they would have remained with the federal government),” the report said. “Roughly 75 to 80% of Medicaid expansion spending represents new spending in Montana’s economy.”

Wernham said it’s not just money coming to the state government, it’s money that’s going directly into Montana’s communities, large and small, “to hire people, and those people will need goods and services.”

Who is in the program?

More than one in five Montanans are part of the Medicaid expansion, or 22% of the state population. That number has actually dropped because of the “redetermination” process the state implemented after the COVID-19 pandemic in which those who were enrolled were kept on the program until the conclusion of the health emergency. The effects of that can be seen in the overall numbers. The uninsured population of Montana had been steadily decreasing since expansion in 2015 from 16.4% then to a low of 10.7% in 2021. That number has begun to creep up since redetermination, and now stands at 12%.

In his report, “Economic Effects of Medicaid Expansion in Montana,” economist Ward noted that Medicaid expansion is at its lowest number of enrollees since 2017, when the program was just ramping up. His report points to two possible scenarios.

The first thing that may be effecting the rate of enrollment has been an overall rise in income in Montana, which would lead to better paying jobs, making private insurance affordable, or jobs that offer it as part of a benefit package.

“Income in Montana increased substantially over the past several years. As a result, the number of Montanans with income below 139% of the federal poverty level declined by 11% between 2019 and 2023,” the report said.

However, Ward said it is “unclear” whether that alone provides a complete answer. He said that the challenges experienced by “redetermination,” a process that generated criticism and outrage toward the Montana Department of Public Health and Human Services, could explain some of the drop, too.

“Montana ranks high in both the share of population that reported losing Medicaid coverage (8.4% versus 6.1% percent in the median expansion states) and the share of those who lost coverage and could complete the redetermination process (24.1% versus 15.5% in the median expansion states). Thus two percent of Montana’s population cited the inability to complete the redetermination process as the reason for losing Medicaid,” the report said.

Ward also pointed out that the percentage of people who were classified as “uninsured” also rose at a much higher clip.

“Medicaid enrollment may be artificially low due to redetermination challenges,” the report said.

One of the main concerns expressed by lawmakers is that those covered by Medicaid expansion are not in the workforce. However, the reports found that Medicaid expansion residents are either in the labor force, are in school, disabled, or a caregiver. Only 6% of those covered don’t match one of those descriptions. The 2025 report continues to track data changes year by year, and found that in Montana, 58% spend less than three years on the program.

In the separate report, authored by Ward, the analysis found that “Medicaid expansion does not reduce economic capacity by reducing labor force participation.”

In fact, the labor force participation, especially for the group of people between the ages of 19 and 64, increased from 81% to 83% between 2015 and 2023 — the period of Montana’s expansion.

Ward also studied the types of workers who are in the Medicaid expansion, and found that Montana residents in the services and hospitality, as well as younger workers in a multi-job “gig economy” rely on Medicaid expansion.

For example, the report found that 26% of all Montana’s food preparation and service workers rely on Medicaid and they work an average of 1,448 hours per year at a median hourly wage of $13.59. Other notable categories of employees include personal care employees, recreation and entertainment employees, and farming, fishing and forestry, many of whom work more than full-time, according to the report.

“Since expanding Medicaid, overall adult labor force participation increased in Montana, and the change is almost exactly aligned with the change observed in non-expansion states,” the report said. “This is not consistent with what one would expect if Medicaid expansion was adversely affecting labor force participation.”

Wernham noted that overall Medicaid in Montana covers 13% of the workforce.

“Most of the people in Medicaid expansion are working, and they’re working in sectors that we believe are essential,” Wernham said.

A healthier Montana

The annual study also documented a rise in the number of preventative screenings for diseases like cancer and diabetes, which has also meant that some chronic conditions were detected earlier.

In 2023, more than 52,000 adults went to the dentist for preventative screenings, which represents a 277% increase from the number of dental screenings provided in 2015. Moreover, screening for cholesterol increased by 405% since 2015.

The data suggests that more than 1,400 cases of cancer were averted, with breast cancer and colon cancer the top types. Other categories of care also increased. For example, hypertension treatment has risen by 312% since expansion; diabetes cases treated has risen 245%; and substance use disorder treatment has seen a 636% increase.

Over time, the study tracked the new enrollees’ trips to the emergency room, often the most expensive care available. For patients enrolled in the expansion for more than two years, the 2025 report suggests that there is nearly a 10% drop in need for the services, and over time, that number continues to decrease.

Trips to the emergency room for preventable dental diseases also plunged by nearly 40% for those enrolled for more than three years.

More money to spend

The reports emphasize that because of Medicaid expansion, Montana residents have more money to spend. Ward’s analysis says that Montana households are spending $175 million to $300 million that would have otherwise gone to medical bills.

Not only has Medicaid’s expansion in Montana meant more jobs and more money for other parts of the economy, it has also appeared to have reduced the financial stress on other families as Montana households with medical debt falling from 17% in 2015 to 4% in 2023, according to the report.

“The idea that as many as 80,000 people are now largely free of medical debt — that has a significant impact on the economy,” Wernham said.

More savings for the state

It seems contrary to what someone might expect, Ward’s report said, but Medicaid expansion is actually saving the state money, and not just because the federal government covers as much as 90% of the cost.

Reductions in full Medicaid coverage versus expansion — in other words the number of people who utilize expansion, versus the traditional plan which comes at a much higher state contribution — have meant that more people are covered and yet the State of Montana spends less. Montana’s contributions toward Medicaid expansion, which range from 11% to 13% are still below other comparable states, too.

“Data strongly suggest that the savings within traditional Medicaid offset a substantial portion of the state’s share of expansion costs,” Ward’s report said. “The savings observed in Montana are not unusual; states that expand Medicaid typically experience similar declines in traditional Medicaid costs.

“Legislative Fiscal Division estimates that Medicaid expansion has effectively zero impact on the state general fund,” the report said.

Read the full 2025 Medicaid in Montana Annual report here.

Read the full Medicaid Expansion Economic Impact report here.