In MT, Medicaid expansion compromise lives another day

Rep. Art Wittich (R-Belgrade) reviews a draft plan to burn Midgetville.

Rep. Art Wittich (R-Belgrade) reviews a draft plan to burn Midgetville.

Montana is one of about 20 states that have not yet expanded Medicaid coverage in compliance with the Affordable Care Act. During the 2013 legislative session, the bill to accept federal funds for expansion failed by one vote, after Mark Jacobson (D-Great Falls) accidentally voted against it when he thought he was voting for it. This year, the original bill to expand Medicaid never made it out of the House Health and Human Services Committee, which is chaired by bulwark of personal responsibility Art Wittich.

Fortunately, Sen. Ed Buttrey (R-Great Falls) developed a compromise bill intended to mollify conservatives in his caucus by ensuring that no one got Medicaid coverage for free. Under SB 405, recipients of expanded Medicaid will have to pay a token premium totaling 2% of their income annually. This expedient heads off the tea party objection that it’s wrong to give people free health insurance.1 It also costs $11 million. That’s how much we expect a third-party insurer to charge to process payments for a program the federal government administers gratis. We’ve spent $11 million to make sure nobody gets anything for free.

That’s conservatism for dummies, as I explain in this week’s column in the Missoula Independent. I wrote it Monday afternoon, before Wittich’s committee killed SB 405 and made it the object of a crazy rules battle. At one point, 40 Republicans voted to adjourn the entire 2015 legislative session to keep SB 405 from reaching the floor. But Democrats have held Republicans to the “silver bullet” bargain they made at the beginning of the session, despite Speaker Knudsen’s display of bad faith, and the House will vote on Medicaid expansion this afternoon. Probably, team compromise will win, and Montana will finally get $5 billion and health insurance for 7% of its population. And we’ll only have to pay $11 million to satisfy the vocal minority who understand politics from reading chain emails.

Never forget, though, that the conservative wing of the Montana Republican Party insisted on spending millions of dollars to make sure nobody got anything free. Putting theory ahead of pragmatism like that is the opposite of conservatism. Probably, the Montana legislature will do the right thing in spite of itself today. But the people who had to be cajoled into it with inefficiency should not call themselves conservatives.

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  1. Your point is well taken. I just want to quibble with one line:
    “Bronson’s unexpected slant rhymes and inexplicably evocative images make Mr. Wonderful a kind of overdose dream where the narrative exists between allusions.”

    Whoops, that was from your excellent column about music. I mean this line:
    “The 70,000 uninsured Montanans who should have gotten coverage under expanded Medicaid but haven’t yet are costing hospitals—and therefore premium-paying, insured Montanans—millions of dollars a year in emergency room visits.”

    This line implies that if covered by Medicaid the millions of dollars in emergency room visits would be reduced. However, that aint so. From this paper: In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage using a randomized controlled design. Using the randomization provided by the lottery and emergency department records from Portland-area hospitals, we study the emergency department use of about 25,000 lottery participants over approximately 18 months after the lottery. We find that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40 percent relative to an average of 1.02 visits per person in the control group. We find increases in emergency department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.

    Now, just because emergency room costs go up when you insure people does not mean we shouldn’t do it, but it does mean we need to modify how we talk about the benefits of expanding Medicaid. This article suggests some talking points once you take that arrow out of your quiver.

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