Medicaid expansion: The big impact of a big part of Obamacare that’s still going strong

Ian Ballard

This is the first installment of a three-part series, examining the impacts and future of expanded Medicaid in Montana.

KALISPELL – Not long after Ian Ballard returned from Kansas City to Kalispell to help with a family funeral, he experienced shooting pain through his legs and back, and at times could barely walk.

The 42-year-old bartender and restaurant manager also had left his job behind and was without health insurance.

Ballard says he went to the Flathead Community Health Center to ask about insurance and was told he might be eligible for Montana’s newly expanded Medicaid coverage.

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Within weeks, he had the coverage, free of charge, and was diagnosed with a rare form of necrosis, which had severely degenerated both of his hips. Earlier this year, Ballard had both hips replaced – and, late this year, returned to work in the restaurant business.

“Had I not had the coverage, I don’t know where I would have turned,” he told MTN News in a recent interview. “I probably would have just kept suffering through.”

Ballard is one of 86,000 low-income adults in Montana who’ve now qualified for basically free coverage under Medicaid expansion, which is one of the surviving cornerstones of the Affordable Care Act – also known as “Obamacare.”

The Trump administration and Republicans in Congress have begun chipping away at other elements of the ACA, but Medicaid expansion remains largely intact in the 31 states that chose to accept it, including Montana.

The government-funded coverage is available to childless adults who earn up to 138 percent of the federal poverty level – about $16,600 a year for a single person or $22,400 for a couple.

However, state data show that nearly three-fourths of the people signing up for Medicaid coverage are earning less than 51 percent of the federal poverty level – a mere $6,000 a year.

The coverage began in January 2016, authorized by a coalition of Democrats and moderate Republicans at the 2015 Montana Legislature. The federal government paid 100 percent of the cost through 2016, but its share gradually decreases to 90 percent by 2020.

The program spent $735 million during its first 18 months in Montana, on medical care for those covered, and is projected to spend another $1.25 billion through mid-2019. All but $100 million or so is federal money.

About 45 percent of the money went to hospitals, clinics and related services during the first 18 months, but the rest has been spread over the entire health-care spectrum, including prescription drugs, dental care, psychiatric care and addiction treatment.

Health-care professionals across the state say the expansion has had a huge impact, enabling them to provide needed services to thousands of Montanans who previously couldn’t afford the care.

“Whether we like it or not, (coverage) means access to health care for a lot of people,” says Heidi Duncan, a family-medicine physician at Billings Clinic, the largest hospital in the state. “When you have more people insured, through expanded Medicaid, then they’re much more likely to get in for their preventive services and look for things early on.”

Yet the Legislature authorized the expansion only through mid-2019 and will re-evaluate the program that year and decide whether to renew it.

Rep. Greg Hertz, R-Polson, who voted against the expansion in 2015, notes that the administration of Democratic Gov. Steve Bullock substantially underestimated how many people would sign up, and said he’s concerned about the long-term cost to the state.

“There is no doubt about it – it’s helped many individuals across the state,” he told MTN News. “But If we’re going to fund this (program) to the level that we need to, what other programs are we going to have to cut back in the state?”

The Bullock administration estimated in 2015 that about 40,000 Montanans would be signed up for coverage under Medicaid coverage by 2018 – less than half the amount it’s become.

Department of Public Health and Human Services Director Sheila Hogan, a Bullock appointee, told MTN News that advocates of expansion had always estimated that about 70,000 Montanans could be eligible for expanded Medicaid coverage. The lesser estimate for 2018 assumed that people wouldn’t sign up as quickly as they have, she says.

“So we really aren’t over by that much,” she says. “To me, it shows pent-up demand for primary care … It just went a lot quicker than we anticipated. It shows a need.”

Hogan says the Bullock administration will be arguing strongly in 2019 for extension of the program.

“Medicaid expansion has brought in $800 million of health-care services in 18 months,” she says. “That’s almost a billion dollars, in treating the health of Montanans.”

For Montanans like Ballard, the expansion has been a medical lifeline.

Ballard says he has worked his entire adult life, paid for health insurance during that time and rarely used it. But it wasn’t until he came home to Kalispell in 2015 to help with his brother’s funeral and affairs that he found himself unemployed and without coverage – and in need of serious medical care.

He says he initially felt embarrassed about accepting essentially free coverage, but that friends and others pointed out to him that he’d paid taxes for years, and deserved to take advantage of this new piece of the social safety net.

“It’s going to get me back up on my feet, and it’s going to get me back into the workforce, where I can give back,” he says. “I paid for (health) insurance for the better part of two decades … and never expected anything back for it. So now, I just find myself in a situation where it does pay me back.”

While Ballard was out of work when he qualified for Medicaid coverage, many Montanans who have the coverage also have jobs.

Celeste Thompson of Missoula, who works as a home-healthcare aide, says she doesn’t work enough hours to get coverage through her employer and couldn’t afford it elsewhere.

Prior to Medicaid expansion, she had to resort to charity care when she was treated for endometrial cancer. But now that she’s covered, she says she’s been able to have regular post-treatment checkups and arrange for other health-care items she’d put off for years, such as new glasses and dentures.

“I would only go to the doctor when it was absolutely necessary, because I couldn’t afford to otherwise,” she told MTN News. “(Medicaid expansion) is a god-send. I don’t have to worry about how I’m going to pay for doctor visits and that sort of thing.”

And Frank Keele, who operates tow-truck companies in Billings, says before Medicaid expansion, he couldn’t find any health insurance he could afford – and that he dearly needed some medical care.

Since he’s been covered by Medicaid, Keele has had a long-troubled gall bladder removed, had two stents inserted to improve his circulation and been able to afford medicines for a variety of ailments.

“It’s the difference between life and death,” he told MTN News. “You take this away from me, you can just as well sign my death certificate. … A lot of people out there don’t have any money, and don’t have the prospect of getting any money. Is that why we’re just supposed to let them die? I don’t think so.”

Next: Medicaid expansion has had a huge impact on health care for Montanas Native Americans and clinics that serve low-income patients.

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