Conservative groups are working to undermine support for Montana’s Medicaid expansion in hopes the state will abandon the program. The rollback would be the first in the decade since the Affordable Care Act began allowing states to cover more people with low incomes.

Montana’s expansion, which insures roughly 78,800 people, is set to expire next year unless the legislature and governor opt to renew it. Opponents see a rare opportunity to eliminate Medicaid expansion in one of the 40 states that have approved it.

The Foundation for Government Accountability and Paragon Health Institute, think tanks funded by conservative groups, told Montana lawmakers in September that the program’s enrollment and costs are bloated and that the overloaded system harms access to care for the most vulnerable.

Manatt, a consulting firm that has studied Montana’s Medicaid program for years, then presented legislators with the opposite take, stating that more people have access to critical treatment because of Medicaid expansion. Those who support the program say the conservative groups’ arguments are flawed.

State Rep. Bob Keenan, a Republican who chairs the Health and Human Services Interim Budget Committee, which heard the dueling arguments, said the decision to kill or continue Medicaid expansion “comes down to who believes what.”

The expansion program extends Medicaid coverage to adults with incomes up to 138% of the federal poverty level, or nearly $21,000 a year for a single person. Before, the program was largely reserved for children, people with disabilities, and pregnant women. The federal government covers 90% of the expansion cost while states pick up the rest.

National Medicaid researchers have said Montana is the only state considering shelving its expansion in 2025. Others could follow.

New Hampshire legislators in 2023 extended the state’s expansion for seven years and this year blocked legislation to make it permanent. Utah has provisions to scale back or end its Medicaid expansion program if federal contributions drop.

FGA and Paragon have long argued against Medicaid expansion. Tax records show their funders include some large organizations pushing conservative agendas. That includes the 85 Fund, which is backed by Leonard Leo, a conservative activist best known for his efforts to fill the courts with conservative judges.

The president of Paragon Health Institute is Brian Blase, who served as a special assistant to former President Donald Trump and is a visiting fellow at FGA, which quotes him as praising the organization for its “conservative policy wins” across states. He was also announced in 2019 as a visiting fellow at the Heritage Foundation, which was behind the Project 2025 presidential blueprint, which proposes restricting Medicaid eligibility and benefits.

Paragon spokesperson Anthony Wojtkowiak said its work isn’t directed by any political party or donor. He said Paragon is a nonpartisan nonprofit and responds to policymakers interested in learning more about its analyses.

“In the instance of Montana, Paragon does not have a role in the debate around Medicaid expansion, other than the testimony,” he said.

FGA declined an interview request. As early as last year, the organization began calling on Montana lawmakers to reject reauthorizing the program. It also released a video this year of Montana Republican Rep. Jane Gillette saying the state should allow its expansion to expire.

Gillette requested the FGA and Paragon presentations to state lawmakers, according to Keenan. He said Democratic lawmakers responded by requesting the Manatt presentation.

Manatt’s research was contracted by the Montana Healthcare Foundation, whose mission is to improve the health of Montanans. Its latest report also received support from the state’s hospital association.

The Montana Healthcare Foundation is a funder of KFF Health News, an independent national newsroom that is part of the health information nonprofit KFF.

Bryce Ward, a Montana health economist who studies Medicaid expansion, said some of the antiexpansion arguments don’t add up.

For example, Hayden Dublois, FGA’s data and analytics director, told Montana lawmakers that in 2022 72% of able-bodied adults on Montana’s Medicaid program weren’t working. If that data refers to adults without disabilities, that would come to 97,000 jobless Medicaid enrollees, Ward said. He said that’s just shy of the state’s total population who reported no income at the time, most of whom didn’t qualify for Medicaid.

“It’s simply not plausible,” Ward said.

A Manatt report, citing federal survey data, showed 66% of Montana adults on Medicaid have jobs and an additional 11% attend school.

FGA didn’t respond to a request for its data, which Dublois said in the committee hearing came through a state records request.

Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, also declined to comment. As of late October, a KFF Health News records request for the data the state provided FGA was pending.

In his presentation before Montana lawmakers, Blase said the most vulnerable people on Medicaid are worse off due to expansion as resources pool toward new enrollees.

“Some people got more medical care; some people got less medical care,” Blase said.

Reports released by the state show its standard monthly reimbursement per Medicaid enrollee remained relatively flat for seniors and adults who are blind or have disabilities.

Drew Gonshorowski, a researcher with Paragon, cited data from a federal Medicaid commission that shows that, overall, states spend more on adults who qualified through the expansion programs than they do on others on Medicaid. That data also shows states spend more on seniors and people with disabilities than on the broader adult population insured by Medicaid, which is also true in Montana.

Nationally, states with expansions spend more money on people enrolled in Medicaid across eligibility groups compared with nonexpansion states, according to a KFF report.

Zoe Barnard, a senior adviser for Manatt who worked for Montana’s health department for nearly 10 years, said not only has the state’s uninsured rate dropped by 30% since it expanded Medicaid, but also some specialty services have grown as more people access care.

FGA has long lobbied nonexpansion states, including Texas, Kansas, and Mississippi, to leave Medicaid expansion alone. In February, an FGA representative testified in support of an Idaho bill that included an expansion repeal trigger if the state couldn’t meet a set of rules, including instituting work requirements and capping enrollment. The bill failed.

Paragon produced an analysis titled “Resisting the Wave of Medicaid Expansion,” and Blase testified to Texas lawmakers this year on the value of continuing to keep expansion out of the Lone Star State.

On the federal level, Paragon recently proposed a Medicaid overhaul plan to phase out the federal 90% matching rate for expansion enrollees, among other changes to cut spending. The left-leaning Center on Budget and Policy Priorities has countered that such ideas would leave more people without care.

In Montana, Republicans are defending a supermajority they didn’t have when a bipartisan group passed the expansion in 2015 and renewed it in 2019. Also unlike before, there’s now a Republican in the governor’s office. Gov. Greg Gianforte is up for reelection and has said the safety net is important but shouldn’t get too big.

Keenan, the Republican lawmaker, predicted the expansion debate won’t be clear-cut when legislators convene in January.

“Medicaid expansion is not a yes or no. It’s going to be a negotiated decision,” he said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism.

BILLINGS, Mont. (AP) — Democrats’ crushing loss in Montana’s nationally important U.S. Senate race settled a fierce political debate over whether a surge of newcomers in the past decade favored Republicans — and if one of the new arrivals could even take high office.

Voters answered both questions with an emphatic “yes” with Tim Sheehy’s defeat of three-term Democratic Sen. Jon Tester, helping deliver a GOP Senate majority and laying bare a drastic cultural shift in a state that long prided itself on electing home-grown candidates based on personal qualifications, not party affiliation.

It’s the first time in almost a century that one party totally dominates in Montana. Corporations and mining barons known as the Copper Kings once had a corrupt chokehold on the state’s politics, and an aversion to outsiders that arose from those times has faded, replaced by a partisan fervor that Republicans capitalized on during the election.

Tester, a moderate lawmaker and third-generation grain farmer from humble Big Sandy, Montana, lost to wealthy aerospace entrepreneur Sheehy, a staunch supporter of President-elect Donald Trump who arrived in Montana 10 years ago and bought a house in the ritzy resort community of Big Sky.

“The political culture in Montana has changed fundamentally over the past 10 to 15 years,” said University of Montana history professor Jeff Wiltse. “The us vs. them, Montanans vs. outsiders mentality that has a long history in Montana has significantly weakened.”

The state’s old instinct for choosing its own, regardless of party, gave way to larger trends that began more than a decade ago and accelerated during the pandemic.

Job opportunities in mining, logging and railroad work — once core Democratic constituencies — dried up. Newcomers, many drawn by the state’s natural social distancing, came in droves — with almost 52,000 new arrivals since 2020. That’s almost as many as the entire prior decade, according to U.S. Census data. As the population changed, national issues such as immigration and gender identity came to dominate political attention, distracting from local issues.

The 2024 Senate race brought a record-setting flood of outside money on both sides — more than $315 million, much of it from shadowy groups with wealthy donors. That effectively erased Montana’s efforts over more than a century to limit corporate cash in politics.

Sheehy’s win came after the party ran the table in recent Montana elections where voters installed other wealthy Republicans including Gov. Greg Gianforte, U.S. Sen. Steve Daines and U.S. Rep.-elect Troy Downing.

Daines is the only one of the group originally from Montana — once a virtual requirement for gaining high office in the state.

Apple-flavored whiskey and Champagne

The contrast between Montana’s old and new politics was on vivid display on election night. Tester’s party was a sedate event at the Best Western Inn in Great Falls — rooms for $142 a night — where the lawmaker mingled with a few dozen supporters and sipped on apple-flavored whiskey in a plastic cup.

Sheehy’s more boisterous affair was in Bozeman — the epicenter of Montana’s new wealth — at an upscale hotel where a standard room costs $395. Long before his victory was announced, carts bearing Champagne were rolled in as the candidate remained sequestered in a secure balcony area most of the night with select supporters.

Sheehy, a former U.S. Navy SEAL from Minnesota, moved to Montana after leaving the military and, along with his brother, founded Bridger Aerospace, an aerial firefighting company that depends on government contracts. Sheehy also bought a ranch in the Little Belt Mountains, and during the campaign cast himself as the modern equivalent of an early western settler seeking opportunity.

Tester received 22,000 more votes on Nov. 5 than in his last election — a gain that exceeded his margin of victory in previous wins. Yet for every additional Tester voter, Sheehy gained several more. The result was a resounding eight-point win for the Republican, removing Democrats from the last statewide office they still held in Montana.

For Republicans, it completed their domination of states stretching from the Northern Plains to the Rocky Mountains.

“We have North Dakota, South Dakota, Montana, Wyoming, Utah — we’re all kind of red now,” said Montana Republican Party Chairman Don Kaltschmidt.

Democrats as recently as 2007 held a majority of Senate seats in the Northern Plains and almost every statewide office in Montana.

Daines — who led GOP efforts to retake the Senate as chairman of the National Republican Senatorial Committee — pointed out during Sheehy’s election party that Republicans would control both Montana Senate seats for the first time in more than a century.

‘Conservative refugees’

Tester and other Democrats bemoan the wealth that’s transformed the state. It’s most conspicuous in areas like Big Sky and Kalispell, where multimillion-dollar homes occupy the surrounding mountainsides while throngs of service workers struggle to find housing.

It’s not quite the same as the Copper Kings — who at their peak controlled elected officials from both major parties — but Democrats see parallels.

“What do they say — history doesn’t repeat itself but it rhymes,” said Monica Tranel, the defeated Democratic candidate in a western Montana House district. “It is very evocative of what happened in the early 1900s. It’s very much a time of change and turmoil and who has a voice.”

Montana in 2022 gained a second House seat due to population growth over the prior decade, giving Democrats a chance to regain clout. After a narrow loss that year to former Trump Interior Sec. Ryan Zinke, Tranel ran again this year and lost.

Even as she turned to history to explain Montana’s contemporary political dynamic, Tranel considered the future. She acknowledged that Democrats have fallen out of step with a conservative electorate more attuned to party labels.

“The label itself is what they are reacting to,” she said. “Do we need a different party at this point?”

Republican officials embraced wealthy newcomers.

Steve Kelly, 66, who calls himself a “conservative refugee,” moved to northwestern Montana from Nevada at the height of the pandemic. He spent most of his 30-year career in law enforcement in Reno, but said he tired of the city as it grew and became more liberal — “San Francisco East,” he called it.

In 2020, Kelly and his wife bought a house outside Kalispell on a few acres so they could have horses. He got involved with the local Republican party and this fall won a seat in the state Legislature on an anti-illegal immigration platform.

“It seems to be different here. Most of the people we have met have also been conservative refugees, getting away from other cities,” he said.

Driving the growth are transplants from western states dominated by Democrats, especially California, where more than 85,000 Montana residents originated, or about 7.5% of the population, Census data shows. Almost half of Montana residents were born out of state.

Worker wages in Montana have been stagnant for decades, said Megan Lawson with the independent research group Headwaters Economics in Bozeman. Income from stocks, real estate and other investments has risen sharply, reflecting the changing — and wealthier — demographic.

“Certainly a large share of it is coming from folks who are moving into this state,” Lawson said. “When you put all this together it helps to explain the story of the political shift.”

___

Associated Press reporter Michael Schneider in Orlando, Florida, contributed to this report.

The question of who uses which bathroom on Capitol Hill has become a heated topic ahead of the 119th U.S. Congress convening next year.

This debate was sparked by the historic election of Sarah McBride, a transgender woman, to represent Delaware in Congress. In response, Rep. Nancy Mace (R-S.C.) introduced a resolution aiming to require transgender individuals to use bathrooms corresponding to their sex assigned at birth.

Democratic state Rep. Zooey Zephyr, the first transgender woman in Montana’s state legislature, understands what it feels like to be singled out.

She joined Scripps News on Friday to weigh in on the controversy unfolding in D.C.

“It’s important to acknowledge that while these attacks on transgender people are always brought one bill at a time, they do not focus on specific issues,” Zephyr said. “The hate of trans people is boundless. We saw that when Nancy Mace went on far-right media earlier this week and claimed that it was ‘offensive’ that Congresswoman McBride views herself as an equal to Nancy Mace.”

“When we see policies targeting trans women just trying to live their lives in the restroom, trying to play sports with their friends — that is not where the hate stops from the right,” Zephyr said. “That hate is on display at every moment, which is why it’s important for us to resist these efforts to target our community.”

In 2023, Republican lawmakers in Montana voted to ban Zephyr from the House floor and from participating in debates after she spoke out against a bill banning gender-affirming care for minors. The incident led to legal challenges over Zephyr’s censure and to political activism from supporters of transgender rights.

“The attacks we see on trans people will escalate. This will not be the last attack on Congresswoman McBride,” Zephyr said. “In my perspective, it is important that we make sure as trans people in this country that we do not cede ground to someone who wants to erase us — regardless of whether they want to erase us in the Capitol, or if they want to erase us as we go through our daily lives in public. We have to stand strong.”

Rep. Nancy Mace to introduce bill on restroom use tied to sex at birth

In an interview with Scripps News this week, Mace said her resolution was specifically targeted at Rep.-elect McBride, who stated she will “follow the rules as outlined” even if she disagrees with them.

“I’m not here to fight about bathrooms,” McBride said. “I’m here to fight for Delawareans to bring down the costs facing families.”

Despite McBride’s statement, Mace said her effort to ban transgender individuals from certain bathrooms extends beyond Washington. She is advocating for legislation requiring transgender people to use restrooms that align with their sex assigned at birth on any property receiving public funds.

“I have PTSD from the sexual abuse I have suffered at the hands of a man. We have to as women draw a line in the sand, a big fat red line, about our rights,” Mace said. “And the basic question today is, do women have rights or do we not? And I will tell you just the idea of a man in a locker room watching me change clothes after a workout is a huge trigger and it’s not OK to make and force women to be vulnerable in private spaces.”

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