Two Montana lawmakers, one Republican and one Democratic, advocated Wednesday for their strategies to continue Medicaid expansion, while another Republican pitched his plan to end the state’s program. The bill hearings triggered hours of testimony from supporters of the low-income health coverage plan, scheduled to sunset this year unless extended by legislators.

People who wanted to speak before lawmakers about the three bills packed committee rooms, spurring nearly five hours of hearings that stretched until 7:30 p.m. The fate of Medicaid expansion is anticipated to be one of the most hotly debated policies in the 90-day legislative session.

“Medicaid expansion has been transformative,” said Gene Small, president of the Northern Cheyenne Tribe, one of dozens of proponents who appealed to lawmakers to continue the program. “Moving forward with this legislation is the moral choice for the most vulnerable among us.”

Medicaid, a decades-old public health program created by Congress, was expanded to adults with incomes up to 138% of the federal poverty level under the Affordable Care Act, an option that 41 states decided to adopt. A bipartisan group of Montana lawmakers voted to extend coverage to that population in 2015 under the Health and Economic Livelihood Partnership (HELP) Act. State legislators agreed to renew the law in 2019. 

The cost of the expanded program, used by more than 76,000 Montana adults as of October, is almost entirely covered by the federal government. The upfront cost to the state’s coffers was roughly $100 million in the last fiscal year. 

As the program has grown in size and expense, so too has opposition among a coalition of Republican lawmakers, driving a wedge in the GOP caucus. Original estimates forecasted that roughly 45,000 people would be enrolled by 2019.

Two Republican-sponsored bills heard Wednesday would create dramatically different paths for the future of the program. The GOP holds wide majorities in both the House and Senate, but it’s unclear how party members will respond to Medicaid expansion proposals that reach the floor. Republican Gov. Greg Gianforte has indicated support for the program continuing in some form. 

House Bill 245, sponsored by Rep. Ed Buttrey, R-Great Falls, would strike the termination date from the HELP Act and adjust the work requirements that lawmakers passed in 2019. Those requirements were later blocked by the Biden administration and never took effect.

Buttrey, who successfully sponsored Medicaid expansion in prior sessions by building a coalition of Democrats and moderate Republicans, told lawmakers on the House Human Services Committee Wednesday that continuing the program was essential for uplifting people struggling to make ends meet and for Montana’s broader business landscape.

“If as legislators we choose to bury our heads in the sand and ignore the physical and mental needs of our low-income population in Montana, to ignore the addiction issues that we have and ignore the value of a healthy and unaddicted workforce, we will pay for it down the road,” Buttrey said. “And we’ll pay a heck of a lot more than we’re paying now.”

Buttrey, who appeared on the verge of tears while reflecting on the policy’s history, also stressed the overall impact Medicaid expansion has had on Montana’s economic landscape and state budget.

“We’ve created a system that, unlike in other states, actually moves people out of poverty and onto their own success. Our system puts health care back in the doctor’s offices and out of the emergency rooms. Our system has enhanced the pool of workers available to our businesses,” Buttrey said. “All of this while providing positive savings to our General Fund and to the taxpayers of Montana.”

Buttrey’s bill received support from more than 60 people, testifying in person and online. Many drove across the state to speak in favor of Buttrey’s proposal, stressing its importance to rural and tribal communities. None spoke in opposition.

A very different Republican proposal, introduced by Sen. Carl Glimm, R-Kila, was heard at the same time in a committee room down the hallway of the state Capitol. 

Glimm’s bill, Senate Bill 62, would phase out the Medicaid expansion program beginning later this year. The measure directs the state health department to stop accepting new enrollees beginning Sept. 1. 

“People that don’t qualify anymore will start to work themselves off and eventually we would not have anybody on Medicaid expansion,” Glimm told the Senate Public Health, Welfare and Safety Committee.

Glimm, in arguing to end expansion, cited concerns that the federal government could change its contributions to Medicaid, leaving Montana on the hook for more than the 10% of the program it currently pays for. Glimm also argued that Medicaid expansion unjustly subsidizes health coverage for unemployed people who don’t have disabilities.

“This is a financial choice that the state of Montana needs to make,” Glimm said in his prepared remarks. “We need to look at the risks and the benefits and we need to say that able-bodied working adults should be working.”

No proponents spoke in favor of the legislation. Fourteen opponents spoke against the bill, most of whom were representatives of health care coalitions, nonprofit organizations and tribal health groups. 

“Medicaid expansion has strengthened the foundation of our health care system, invested in a healthier and more productive workforce and created stronger, more vibrant communities,” said Tylyn Newcomb, community engagement director at the Montana Nonprofit Association.

The governor’s budget office issued a fiscal note for Glimm’s proposal projecting a loss of more than $1.5 billion in federal funds and a cost of more than $800 million to the state General Fund over the next two years if officials from the Centers for Medicare and Medicaid Services declined to continue the current match rate. Glimm told lawmakers he was contesting that calculation, arguing the federal government would continue shouldering 90% of coverage costs for the remaining beneficiaries until the program ends.

The third bill heard Wednesday, House Bill 230, sponsored by Rep. Mary Caferro, D-Helena, would also strike the HELP Act’s termination date and aim to eliminate access hurdles for enrollees. The bill would provide 12 months of continuous eligibility for beneficiaries. It would also strike the HELP Act’s work requirement provision, which Caferro argued are unnecessary. 

Caferro’s legislation also proposes reopening 10 Offices of Public Assistance in rural parts of the state, many of which closed after state budget cuts in 2017. Her bill would also seek to improve communication between enrollees and the state health department by allowing text messages and email communication and creating an advisory board for beneficiaries.

Caferro described the bill to members of the House Human Services Committee as a measure to make the existing program more efficient, particularly after tens of thousands of people lost Medicaid coverage during the state’s mass eligibility review in 2023 and 2024. 

“It takes opportunities to solve problems, creates efficiencies in government … creates accountability in government through public reporting requirements, and transparency in government through a public advisory committee,” Caferro said. “It makes government work for the people.”

About 30 proponents of the bill, many of whom also spoke in favor of Buttrey’s legislation, said it would shore up services for rural residents struggling to navigate a dense web of state bureaucracy, sometimes facing paperwork delays that push back health care services for months. 

All three bills must be supported by a majority of lawmakers on each committee in order to advance to the House and Senate floors. Lawmakers did not vote on the legislation Wednesday night.