CUT BANK — Almost ten years ago, Montana leaders approved an expansion of Medicaid coverage in the state. Today, tens of thousands of people are receiving health care through that expanded program. However, the expansion is set to expire in 2025, unless lawmakers and the governor agree to renew it during the upcoming session of the Montana Legislature.
“I have not personally heard from a rural hospital that did not feel like this was an important, critical issue for their community,” said Cherie Taylor, president of Logan Health-Cut Bank, a 20-bed critical access hospital that serves Glacier County – one of the counties with the largest percentage of residents enrolled in Medicaid. She estimates about 15% of the population they serve qualifies for Medicaid expansion.
Taylor has been with the hospital, formerly known as Northern Rockies Medical Center, for 25 years. She’s been president since 2010, and she says the first few years were “pretty rough,” leading them to scale down some of their operations.
“It wasn't that that people weren't utilizing the services, it was more about, financially, we weren't able to maintain the services,” Taylor said.
One big challenge was the cost of uncompensated care – when a hospital provides care to patients, often in the emergency room, who are unable to pay or don’t have insurance. Taylor says that cost is then borne by their other payers.
“We have very, very slim margins in rural areas, and so to have high uncompensated care on top of that really has a big impact,” said Taylor.
Prior to 2015, Medicaid in Montana was available to children and parents below a low income threshold. That year, the Legislature approved and then-Gov. Steve Bullock signed the HELP Act, which expanded eligibility to include all adults aged 19 to 64 and making less than 138% of the federal poverty level. In 2019, leaders renewed the expansion through June 2025.
Taylor says, as more people became aware of Medicaid expansion, her staff began to see a difference among those they were treating.
“We at times were running in uncompensated care over 10%,” she said. “The very first year, we probably didn't have as much of a huge impact, but then we saw that, over time, it made uncompensated care like drop down to about 2%.”
She says many of the Medicaid expansion recipients they serve are working in service industry jobs, working part-time, going to school or taking care of children or parents – a person living alone and working 40 hours a week at minimum wage would make more than the income threshold to qualify.
“Really people in transition is what we see that are part of the program,” said Taylor. “We've heard quite a few different stories of patients who receive the care that they need, that was important to really getting them to the next step in life, and then they were able to get full-time positions with employers that have commercial insurance. So they themselves, after a period of less than two years, step off the program and go into the commercial market.”
According to a 2024 report from the Montana Healthcare Foundation, Glacier County had 54.8% of its population – 13,681 people – enrolled in Medicaid, both traditional and expanded. Roosevelt, Big Horn, Golden Valley, Rosebud, Hill and Pondera Counties all had more than 40% enrolled. On the other end, Gallatin County had the lowest percentage of Medicaid enrollees, at 14.7%. Broadwater, Carter and McCone Counties were also near the bottom.
The report says, in 2023, an average of 288,810 Montanans were enrolled in Medicaid, and 109,705 of those – about 38% – were on Medicaid expansion.
“It covers people across a wide range of industries in the state,” said Aaron Wernham, CEO of the Montana Healthcare Foundation. “About 30% of people in housekeeping, personal care are covered by Medicaid expansion; 10% or 15% of people in construction and labor are covered. One of the statistics that always stands out for me is 60% of bakers are covered by Medicaid expansion. So a lot of people who really make the economy run: people in retail, people in service.”
The foundation’s reports say the demographics of Montanans on Medicaid expansion are similar to the state as a whole, though a greater share of them are women and a much greater share are Native American. Wernham says they’ve found the average person remains on the program for less than three years.
Wernham says, now that they have almost ten years of data on Medicaid expansion, they’ve seen indicators that the people who got coverage through the program have been less likely to need hospitalization or emergency room care the longer they’ve stayed enrolled.
“People on Medicaid are able to go in and get preventive exams, get wellness exams, get treatment for illnesses like diabetes, get care for injuries that might have taken them to the ER,” he said.
Taylor agreed she’s seen individuals who used to wait for crisis care now getting preventive services. One major area is in behavioral health care, where she says Logan Health-Cut Bank was able to bring in two therapists – in part because they haven’t had as high costs for uncompensated care.
“Now that I have it, not just a Medicaid population are able to utilize the services, but all payers are able to utilize that,” she said.
Taylor says Logan Health-Cut Bank has a gross revenue budget of almost $13 million, and around $2.5 million of that comes from payments for people on Medicaid expansion. However, she says that money is even more significant because they receive that amount in cash – whereas they may charge $13 million overall but don’t receive all that they bill.
“The impact is dramatic,” she said.
The Montana Healthcare Foundation’s report says Montana’s uninsured rate has fallen since Medicaid expansion took effect, from just over 19% in 2014 to around 11% in 2021 and 2022. Wernham said he expects the rate to increase if expansion expires.
“Health coverage is expensive, and so lower-wage workers have a hard time making making up that gap,” he said. “We would expect some people might move into the individual market, some people might be fortunate and get insurance through an employer, and many people would likely become uninsured.”
Taylor says she’s concerned that, if that happens, they could again see the rates of uncompensated care rising to where they were before 2015. If that happens, she says the impact could be even greater now because rising costs are hitting both hospitals and individuals harder.
“You will not just see access issues happen in rural, you'll see it across the entire state of Montana, because it will affect the services that are provided if the uncompensated care drastically goes up,” she said.
EDITOR’S NOTE: This is the first of a two-part story taking a closer look at the issue of Medicaid expansion, ahead of the start of the 2025 Montana legislative session. On Friday, MTN will have more from some of the political leaders who, in the next four months, will debate and decide whether to renew the expansion, make changes to the program, or allow it to expire.
