They recently had a unique opportunity to flex some of that political muscle in Montana, where the state’s Medicaid expansion program was scheduled to expire in June unless legislators and the governor renewed it. 

Conservative lawmakers and groups saw an opportunity to terminate or narrow the Medicaid expansion program that cost about $1 billion in federal and state taxpayer money last year to cover tens of thousands of low-income adults. Ultimately, the conservative Republican lawmakers who occupy state House and Senate leadership positions sought to add requirements to the program or receive concessions from hospitals, such as a promise to bolster their community benefit spending, in return for continuing the program that provides them with revenue. 

What was expected to be one of the more contentious debates of the legislative session never happened. The Medicaid expansion renewal bill sailed through with little difficulty and few changes. 

The hospitals spent the last year working to form a coalition with businesses, health clinics, physician groups, insurers, and advocates for people with low incomes to push for extension of Medicaid expansion, which provides government health coverage to about 74,500 low-income, nondisabled Montanans. That work paid off when Democratic and moderate Republicans lawmakers joined forces to push the bill through. 

Hospital lobbyists, led by the Montana Hospital Association, not only helped steamroll Medicaid expansion through the legislature, but they also defeated nearly all attempts to add new requirements to the program and to place new regulations on the hospitals themselves. 

The hospitals’ political pull is acknowledged by frustrated conservative lawmakers who contend that the facilities, most of which are nonprofit organizations largely exempt from state and federal taxes, need more oversight and transparency. As Republican state Sen. Greg Hertz put it, “Hospitals don’t seem to want to come to the table to discuss anything, whether it’s transparency, controlling costs, or providing more information to the public on services.” 

Hospitals say they’re willing to debate ways to improve health care in Montana. But when it comes to regulations they regard as onerous — or lawmaker criticism that they are uncooperative — they aren’t shy about pushing back. “I think that we’ve demonstrated that we work on all kinds of health policies,” said Montana Hospital Association president and CEO Bob Olsen.

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If Montana’s hospitals wanted to extend the government health insurance program that cost taxpayers about $1 billion in 2024, and benefit from that revenue, they should give something back, such as additional community health care services and benefits, GOP leaders argued as the session began in January.

But instead, they found out just how formidable a political force the state’s hospitals can be. The hospitals not only helped steamroll Medicaid expansion through the legislature, but they also defeated nearly all attempts to add new requirements to the program and to place new regulations on hospitals themselves.

Hospitals opposed and defeated bills and to and killed an attempt to redirect Medicaid funds raised by a hospital tax.

Most Montana hospitals are nonprofit organizations that are largely exempt from state income and property taxes. Legislators requested drafts of several bills to scrutinize hospitals’ “community benefits,” the services they provide for free or at discounted costs that justify their nonprofit status, but did not introduce them during the session.

The has been significantly amended, at the hospitals’ request.

The state hospital lobbyists’ political pull has frustrated conservative lawmakers in leadership positions who are seeking more oversight of and transparency from the hospitals.

“Hospitals don’t seem to want to come to the table to discuss anything, whether it’s transparency, controlling costs, or providing more information to the public on services,” said Republican state Sen. Greg Hertz, who sponsored the price-cap bill that was rejected on the Senate floor this month.

Hospitals say they’re willing to debate ways to improve health care in Montana, and they point to Medicaid expansion as a program whose benefits flow to all corners of the state.

Yet when it comes to regulations they regard as onerous or criticism that they’re uncooperative partners on health care policy, the hospitals aren’t shy about pushing back.

“I don’t think I’ve ever been approached by any of them on reforming the health care system,” Montana Hospital Association president and CEO Bob Olsen said of the hospitals’ critics in the legislature. “I think that we’ve demonstrated that we work on all kinds of health policies.”

Republicans hold big majorities this legislative session and their conservative leaders — most of whom opposed extending Medicaid expansion — have often seen hospitals as a political foe.

But Montana’s hospitals have always been a strong lobby in the state, with bipartisan appeal. The state’s 63 hospitals employ about 30,000 people, according to the MHA, including many of the state’s physicians, and have multiple lobbyists at the Capitol, both on their own and through the hospital association.

They also have a strong ally in state Rep. Ed Buttrey, a moderate Republican who also is on of Benefis Health System. Buttrey sponsored the original and bills to renew the program and .

In the past year, hospitals worked to form a coalition with businesses, health clinics, physician groups, insurers, and advocates for people with low incomes to push for extension of Medicaid expansion, which provides government health coverage to about 74,500 low-income, nondisabled Montanans.

Medicaid expansion had been set to expire this June, but the bill extending it breezed through the legislature, passing by comfortable margins in February, with bipartisan support. Republican Gov. Greg Gianforte signed it into law last month.

The MHA has a political action committee that donates to multiple lawmakers of both parties. In 2024, it paid particular attention to allies of Medicaid expansion.

The PAC gave $61,000 to the Montana Democratic Party and $75,000 to a political committee that supported moderate Republicans in contested GOP legislative primaries last June, according to filings with the state commissioner of political practices.

The majorities that in February included every Democrat in the legislature and many of the moderate Republicans supported by the political committee financed partly by the MHA.

Democrats also have been voting almost universally against bills that would impose new regulations on hospitals.

Hertz’s bill, which would have capped larger hospitals’ prices at 300% of the Medicare rate for most procedures, failed on the Senate floor this month . All but one Democrat and nine Republicans voted against it.

State Sen. , a Democratic member of the Senate Public Health, Welfare and Safety Committee, also voted against a bill requiring nonprofit hospitals to show that their community benefits meet or exceed the value of their property tax exemptions.

Neumann said she supports better access to affordable care in Montana but that “the policies we have been presented with are not well thought out and raise concerns for me about government overreach.”

State Rep. , a Republican who chaired the legislative panel overseeing health care spending in the state budget, tried last month to redirect a small portion of Medicaid expansion funds — $7 million a year — to certain hospitals. The money is part of $365 million generated annually by a tax on hospital services, and the corresponding federal match, according to Olsen, the hospital association leader.

Half of the $7 million would go to smaller, independent hospitals and the other half would be distributed to hospitals showing “exceptional health outcomes and efficiencies,” she said.

The House Appropriations Committee agreed March 24 to insert her proposals into the session’s main budget bill.

But a week later — after hospitals lobbied against the change — the same committee torpedoed language in a separate bill that would have implemented the changes. The next day, on the House floor, all but one Democrat and 25 Republicans to remove the funding change from the budget bill.

“That tells you what a stronghold the hospitals have,” Gillette said. “Even a slight variation to our current system is not acceptable to them.”

Olsen said the change would have taken money from some larger hospitals and moved it elsewhere, and not necessarily to the smaller hospitals Gillette hoped to help.

“She approached us, but never tried to work with us,” he said. “It wasn’t going to reach those hospitals that she wanted to reach.”

Senate President , a Republican, made a last attempt to insert Gillette’s amendment into the state budget bill on the Senate floor on April 17, but it was rejected on a 27-23 vote, with all 18 Democrats and nine Republicans voting no.

Hospitals are, however, working with Regier on his community-benefit reporting measure — the last-standing bill that might impose new regulations on hospitals.

if the community benefits reported by nonprofit hospitals don’t equal or exceed the value of their exemption from property taxes, they must pay the difference into a fund that would be distributed to small, “critical access” hospitals.

During the bill’s initial hearing April 2, Regier — a Medicaid expansion opponent and sometimes sharp critic of the hospitals — said he was open to amendments that hospitals might find acceptable.

The original bill cleared the Senate April 5 on a party-line, 30-18 vote, with Republicans in favor. Then, in a House committee meeting on April 17, Republicans attached amendments that had the hospitals’ blessing and sent the bill to the House floor.

The changes delay the law’s effective date until 2027 and more specifically define the community benefits that must be reported and the potential property tax liability to which hospitals must match their benefit.

Olsen said the MHA will support the amended bill.

“The truth of it is, hospitals have always far exceeded the tax exemption for community benefits, on the spending they do,” he said. “Some might fall short, from time to time — but over the long haul, they exceed those exemptions.”

Regier’s attempt to quantify the amount and compare it to nonprofit hospitals’ tax exemption is not unreasonable, Olsen said: “I’m confident hospitals can do it.”

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“Who in their right mind would subject themselves to this sort of treatment in a business relationship?” said Mike Matovich, a part owner of eight small-town pharmacies in Montana. “It’s such a monopoly. We can be the best pharmacy in the world, and they can still put us out of business.”

, which sailed through the Montana House 98-1 in early March and is now before the state Senate, would set a price floor that PBMs must pay pharmacies for each prescription. Currently, there is no mandated minimum rate in contracts with pharmacies, and independent drugstores said the rates are often below what they paid for the drugs.

The measure includes a half-dozen restrictions on other PBM practices the smaller pharmacies call anticompetitive.

Pharmacy benefit managers, employed by health insurers, are powerful intermediaries in the drug-pricing chain. They determine which drugs are covered by health plans, arrange rebates from drugmakers, and dictate payments that pharmacies receive when selling covered drugs.

The six largest PBMs manage more than 90% of the nation’s drug sales. Most are owned by or affiliated with health insurance giants like UnitedHealth Group, Cigna, Humana, and Aetna.

About 90 Montanan-owned pharmacies are not affiliated with national companies or PBMs, and 10 have closed in the past year, according to Josh Morris, who owns several small-town pharmacies in the state. Morris said his pharmacies lost $30,000 on underpaid drug claims last year and that they lose money on 90% of the brand-name drugs they dispense.

Representatives of independent Montana pharmacies say that without the changes provided by the legislation, more of their ranks will close, because they can’t make ends meet on drug reimbursement prices imposed by what they say are “take-it-or-leave-it” contracts from PBMs.

“We’re filling more prescriptions than ever before, but my employees haven’t had a raise in three years,” Morris said. “Our reimbursements are down 60% since 2019.”

PBMs are mounting a concerted effort in the Montana Senate to kill House Bill 740, arguing it could throw a huge wrench into drug pricing in Montana that would increase consumer costs.

“Not only is it going to cost people, it’s going to change fundamentally how prescription drugs are paid for in the state,” said Tonia Sorrell-Neal of the Pharmaceutical Care Management Association, a trade group representing PBMs. “It takes away the options for employers who are paying for these health plans” to keep drug prices low.

The bill restricts mail-order options for drugs, limits when PBMs can audit claims, and imposes excessive reimbursements, she said.

This battle between PBMs and independent pharmacies isn’t playing out just in Montana — it has roiled statehouses across the country, drawn the attention of Congress, and could end up before the U.S. Supreme Court.

Last summer, the federal and the issued highly critical reports saying PBMs use pricing tactics that keep drug costs high, help pad PBM profits, and harm independent pharmacies.

to crack down on PBMs had been included in a 2024 post-election budget bill before Congress but were stripped out at the last minute after a lobbying push by pharmacy benefit managers.

have passed laws regulating PBM payments to pharmacies and several other states, including California, are considering legislation this year.

Oklahoma passed one of the most expansive laws in 2019. But PBMs sued and won a that said the law does not apply to self-funded health plans, thus removing about two-thirds of the insured population from the law’s jurisdiction.

Oklahoma’s insurance commissioner last year asked the U.S. Supreme Court to overrule the decision, but the court hasn’t decided whether to take the case. from 31 states and the District of Columbia have asked the high court to rule in Oklahoma’s favor; Montana’s AG is not one of them.

In Montana, HB 740’s regulations would apply to PBMs managing self-funded plans, said the state insurance commissioner’s office, which so far supports the bill.

The key element of HB 740 is setting requirements on what PBMs must reimburse pharmacies for each prescription they fill, when that prescription is covered by a health plan using the PBM.

It says the reimbursement can be no less than 106% of the National Average Drug Acquisition Cost, or NADAC — which is determined by a survey of wholesale prices paid by pharmacies — plus a “dispensing fee” for each prescription.

The dispensing fee would be the same as what Montana’s Medicaid program pays pharmacies — $12 to $18 per prescription, depending on the size of the pharmacy. The state Medicaid program also pays the 106% minimum reimbursement.

Montana pharmacies say the dispensing fee covers their basic costs and enables them to make a profit on most sales. Under contracts with most PBMs, the pharmacies say they get no dispensing fee.

The bill also requires other changes in PBM business practices that pharmacies say benefit PBMs and make it harder for independent pharmacies to stay in business.

For example, HB 740 says PBMs cannot offer better prices to pharmacies that they own, cannot charge after-the-fact fees that lower reimbursement rates, cannot slow-walk approval of contracts, and cannot lower payments for drugs sold past a “sell-by” date imposed by the PBMs.

PBM and health plan lobbyists have attacked the bill for its breadth and detail, saying it’s so extensive that nobody truly knows how it may affect prescription-drug markets and prices in Montana.

“This bill has too much,” , an attorney for the Mountain Health Co-Op, told the House Business and Labor Committee at the bill’s first hearing in February. “It has unintended consequences that are severe in the financial world.”

Laura Shirtliff, a spokesperson for the state auditor’s office, said the bill’s provisions should be narrowed, to target assistance for smaller pharmacies.

PBM lobbyists are telling lawmakers to kill HB 740 and instead pass a bill to study the prescription-drug market in Montana, with an eye toward possible solutions to help rural pharmacies.

“I would say there are a lot of elements and factors that are impacting rural pharmacies’ business,” said Sorrell-Neal of the PBM trade group.

Supporters, however, said HB 740 needs to closely define exactly what’s happening in the field, between PBMs and pharmacies, so those practices can be regulated.

As for waiting two years for a study? Pharmacy owners say that’s too late, and that the time to fix the problem is now.

“The amount of damage that would be done in two years will never be able to be recovered from, in these communities,” Matovich said. “Ten years ago, we maybe lost money on five prescriptions a month. Now, it’s thousands of prescriptions a month.”

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“You subscribe to your insurance policy, you pay into that for years and years and years with the hope that, if you need this service, it will be there for you,” Lou Volpe said. “And finally, when you knock on the door and say, ‘Hey guys, we need some help,’ they just start backpedaling.”

The Volpes, who live in Helena, and their health care providers spent more than 18 months pushing for these approvals from Blue Cross and Blue Shield of Montana — including a four-month wait last year for approval of costly infusions that worked to control their son’s disease where other treatments had failed.

“It just really slowed everything down on his treatment, and I feel like he could have been recovering from this situation a lot sooner,” Lindsay Volpe said.

Now, the Volpes, other patients, and their health care providers are bringing the issue to the 2025 Montana Legislature, saying it’s time Montana joined many other states in limiting how and when insurers can deny drugs or treatments through their preapproval process, known as “prior authorization.”

This month, a Democratic and a Republican lawmaker introduced or were drafting separate bills restricting health insurers’ ability to require prior authorization for certain treatments and medications. A third lawmaker was preparing other measures as well.

Many of the state’s medical providers are behind the effort, saying prior authorization is denying vital care and needlessly sucking up more and more of their time, which they say could be better spent with patients.

“It has increased incredibly in the last couple of decades, to the point that it’s one of the leading causes of burnout for physicians,” said Lauren Wilson, a Missoula pediatrician and past president of the Montana chapter of the American Academy of Pediatrics. “It’s just delaying patient care for no good reason.”

Montana health insurers, however, insist they are authorizing drugs and treatments that are shown to be needed. If their review power is stripped away, costs will continue to increase due to insurance paying for unnecessary treatments, they said.

Blue Cross and Blue Shield of Montana said it doesn’t comment on individual cases, such as the Volpes’, but said it approves the “vast majority” of prior authorization requests. Blue Cross, which insures or manages health insurance for 384,000 people in Montana, also said it regularly audits its prior authorization procedures and is taking steps to speed up the process.

“Prior authorizations are a way to ensure members receive the right care at the right place at the right time, avoiding unnecessary services and helping providers understand coverage before a service is delivered,” the company said in a statement.

Denial of care through insurers’ prior authorization processes has struck a nerve nationwide as well.

In the wake of the December shooting death of in New York City, customers of the health insurance giant and other consumers took to social media to denounce the industry for denied claims and puny reimbursements.

And since then, one of the nation’s largest health insurers, The Cigna Group, announced it would spend $150 million this year to reform its prior authorization process and related services for patients and health care providers.

In the past two years, restricting prior authorization, according to the American Medical Association, with New Jersey . The laws, spearheaded by health care providers, generally narrow when and how prior authorization can occur and create stricter timelines for the review.

Legislators in several states, including Indiana, Nebraska, North Dakota, Virginia, and Washington, have introduced prior authorization bills this year.

In Montana, local health insurers aren’t quietly giving in to increased regulation.

They note that state regulation of prior authorization affects only about a fourth of Montanans with health insurance, because large, self-insured plans managed by national health insurers are under federal rules.

State restrictions on prior authorization will increase costs primarily for three in-state insurers, they say — and, eventually, their customers.

“We feel like our job is to say, ‘Is that the best use of money for our membership?’” Jackie Boyle, senior vice president of external affairs for Mountain Health Co-Op, said of prior authorization. “If we approve something, we are doing it for every patient like them.”

Mountain Health, based in Helena, insures 55,000 people in Montana, Idaho, and Wyoming.

Democratic state Rep. Jonathan Karlen of Missoula is sponsoring two bills: for most generic drugs, inhalers, and insulin, and another that says patients can’t be denied a drug when they switch insurers and are waiting for authorization from the new insurer. also says a procedure or treatment may be denied only by a physician with a matching specialty.

Karlen said insurers are putting up barriers to care to increase their profits and said it’s time to break those barriers down.

“People should be making medical decisions based on what they and their doctors think, not what their insurance company thinks,” he said. “If a doctor says you need a medication, that’s why you have insurance — so you can get that.”

Republican state Rep. Ed Buttrey of Great Falls said he plans to introduce a bill to help kids with chronic bowel diseases, such as the Volpes’ son, imposing a seven-day limit to decide whether to authorize expensive biologic treatments. If insurers don’t meet the deadline, the drug would be automatically approved.

Buttrey’s bill also would eliminate most retroactive denials — when insurers refuse to pay for treatment they’d authorized.

State Sen. Vince Ricci (R-Billings) said he is preparing other bills that may include even stronger language to restrict prior authorization for drugs for various conditions.

Health care providers and patients have heard the rationale of insurers and promises that improvements will be made, but they say nothing has happened and that it’s time for the state to step in.

“When there are no consequences and no teeth to anything, I can complain all I want, but it doesn’t seem to incite change,” said Kim Longcake, the pediatric nurse practitioner who’s treating the Volpes’ son.

Longcake said she and another specialist in her office tracked the time they spent on prior authorization requests in a two-week period.

“Depending on where you want to see me, I’m booking out four to six months,” Longcake said. “If I wasn’t spending 12 hours a week doing prior authorization stuff, it would improve access to care.”

The Volpes said their son, now 13, couldn’t absorb food and didn’t gain any weight for a year and a half while he went through treatments that didn’t work and repeated preauthorization waits, including for his current treatment, which appears to be working.

“What he’s gone through at that age was really excessive, beyond what was needed for treatment, because we couldn’t get the care that he needed,” his mother said. “If we didn’t get switched to this medication, he’d still be doing that.”

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The changes, backers say, would fill gaps in services and help people better prepare for life outside of the locked, secure setting of the two state facilities before they reenter their own communities.

“I think part of the theme is responsibly moving people in and out of the state facilities so that we create capacity and have people in the appropriate places,” state Sen. Dave Fern (D-Whitefish) said of the proposed capital projects during a recent interview.

Fern served on the Behavioral Health System for Future Generations Commission, a panel created by a 2023 law to suggest how to spend $300 million to revamp the system. The law set aside the $300 million for improving state services for people with mental illness, substance abuse disorders, and developmental disabilities.

Gianforte’s proposed budget for the next two years would spend about $100 million of that fund on 10 other recommendations from the commission. The capital projects are separate ideas for using up to $32.5 million of the $75 million earmarked within the $300 million pool of funds for building new infrastructure or remodeling existing buildings.

The state Department of Public Health and Human Services and consultants for the behavioral health commission presented commission members with areas for capital investments in October. In December, the commission authorized state health department director Charlie Brereton to recommend the following projects to Gianforte:

• Move the 12-bed Intensive Behavior Center for people with developmental disabilities out of Boulder, possibly to either Helena or Butte, at an estimated cost of up to $13.3 million.
• Establish a “step-down” facility of about 16 beds, possibly on the campus of Shodair Children’s Hospital in Helena, to serve adults who have been committed to the Montana State Hospital but no longer need the hospital’s intensive psychiatric services.
• Invest $19.2 million to upgrade the Montana State Hospital’s infrastructure and buildings at Warm Springs, on top of nearly $16 million appropriated in 2023 for renovations already underway there in an effort to regain federal certification of the facility.

The state Architecture & Engineering Division is reviewing the health department’s cost estimates and developing a timeline for the projects so the information can be sent to the governor. Gianforte ultimately must approve the projects.

Health department officials have said they plan to take the proposals to legislative committees as needed. “With Commission recommendation and approval from the governor, the Department believes that it has the authority to proceed with capital project expenditures but must secure additional authority from the Legislature to fund operations into future biennia,” said department spokesperson Jon Ebelt.

The department outlined its facility plans to the legislature’s health and human services budget subcommittee on Jan. 22 as part of a larger presentation on the commission’s work and the 10 noncapital proposals in the governor’s budget. Time limits prevented in-depth discussion and public comment on the facility-related ideas.

One change the commission didn’t consider: moving the Montana State Hospital to a more populated area from its rural and relatively remote location near Anaconda, in southwestern Montana, in an attempt to alleviate staffing shortages.

“The administration is committed to continuing to invest in MSH as it exists today,” Brereton told the commission in October, referring to the Montana State Hospital.

The hospital provides treatment to people with mental illness who have been committed to the state’s custody through a civil or criminal proceeding. It’s been beset by problems, including the loss of federal Medicaid and Medicare funding due to decertification by the federal government in April 2022, staffing issues that have led to high use of expensive traveling health care providers, and turnover in leadership.

State Sen. Chris Pope (D-Bozeman) was vice chair of a separate committee that met between the 2023 and 2025 legislative sessions and monitored progress toward a 2023 legislative mandate to transition patients with dementia out of the state hospital. He agreed in a recent interview that improving — not moving — MSH is a top priority for the system right now.

“Right now, we have an institution that is failing and needs to be brought back into the modern age, where it is located right now,” he said after ticking off a list of challenges facing the hospital.

State Sen. John Esp (R-Big Timber) also noted at the October commission meeting that moving the hospital was likely to run into resistance in any community considered for a new facility.

Fern, the Whitefish senator, questioned in October whether similar concerns might exist for moving the Intensive Behavior Center out of Boulder. For more than 130 years, the town 30 miles south of Helena has been home, in one form or another, to a state facility for people with developmental disabilities. But Brereton said he believes relocation could succeed with community and stakeholder involvement.

The 12-bed center in Boulder serves people who have been committed by a court because their behaviors pose an immediate risk of serious harm to themselves or others. It’s the last residential building for people with developmental disabilities on the campus of the former Montana Developmental Center, which the legislature voted in 2015 to close.

Drew Smith, a consultant with the firm Alvarez & Marsal, told the commission in October that moving the facility from the town of 1,300 to a bigger city such as Helena or Butte would provide access to a larger labor pool, possibly allow a more homelike setting for residents, and open more opportunities for residents to interact with the community and develop skills for returning to their own communities.

Ideally, Brereton said, the center would be colocated with a new facility included in the governor’s proposed budget, for crisis stabilization services to people with developmental disabilities who are experiencing significant behavioral health issues.

Meanwhile, the proposed subacute facility with up to 16 beds for state hospital patients would provide a still secure but less structured setting for people who no longer need intensive treatment at Warm Springs but aren’t yet ready to be discharged from the hospital’s care. Brereton told the commission in October the facility would essentially serve as a less restrictive “extension” of the state hospital. He also said the agency would like to contract with a company to staff the subacute facility.

Health department officials don’t expect the new facility to involve any construction costs. Brereton has said the agency believes an existing building on the Shodair campus would be a good spot for it.

The state began leasing the building Nov. 1 for use by about 20 state hospital patients displaced by the current remodeling at Warm Springs — a different purpose than the proposed subacute facility.

Shodair CEO Craig Aasved said Shodair hasn’t committed to having the state permanently use the building as the step-down facility envisioned by the agency and the commission.

But Brereton said the option is attractive to the health department now that the building has been set up and licensed to serve adults.

“It seems like a natural place to start,” he told the commission in December, “and we don’t mind that it’s in our backyard here in Helena.”

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In recent interviews, legislative leaders predicted a vigorous debate over keeping the Medicaid expansion program, which pays the medical bills of more than 75,000 low-income Montanans at an annual cost of about $1 billion to the federal and state governments. They also expect the topic to seep into other health policy decisions, such as the approval of new spending on Montana’s behavioral health system and regulation of hospital tax-exempt status.

“It all kind of links together,” said state Sen. Dennis Lenz, a Billings Republican and the chair of the Senate Public Health, Welfare, and Safety Committee.

Legislators from both parties also expect lawmakers from the GOP majority to continue to pursue abortion restrictions, despite a November statewide vote making abortion a right under the Montana Constitution.

The Medicaid expansion debate, however, looms largest among the health care topics.

“This is definitely the elephant in the room, so to speak,” said Senate Minority Leader Pat Flowers, a Belgrade Democrat.

Montana expanded Medicaid, initially for four years, in 2015, through a coalition of minority Democrats, some moderate Republicans, and a Democratic governor. A similar coalition renewed the program in 2019, but at the last moment, Senate Republicans tacked on an end date of June 30, 2025. That put the matter in the lap of this year’s legislature.

Republicans still hold strong majorities in the state House and Senate, whose leaders voiced concerns about the expansion program.

This time around, the governor — Greg Gianforte — is a Republican. Last year, the Gianforte administration completed a postpandemic eligibility reassessment that cut the number of expansion enrollees from a high of 125,000 people in April and May 2023 to approximately 76,600 people as of October, the most recent data available.

Gianforte has included funding for Medicaid expansion in his proposed budget, which must be approved by the legislature to take effect. His office said he wants “strong work requirements for able-bodied adults without dependents” to take part in the program. Spokesperson Kaitlin Price said the governor “has been clear that the safety net of Medicaid should be there for those who truly need it, but that it will collapse if all are allowed to climb on it.”

GOP legislative leaders clearly are skeptical of the program, saying it won’t continue without some “sideboards,” or additional requirements of enrollees and providers.

Whether any expansion bill passes “will depend on the people pushing it,” said Senate President Matt Regier, a Kalispell Republican who opposes expansion. “If there is no give-and-take, it could be an interesting vote.”

Flowers said he knows getting Medicaid expansion through the Senate will be tough. Republicans hold a 32-18 majority, and the GOP caucus leans conservative.

“There are a lot of my colleagues on the Republican side that are ideologically opposed, and I think you’re going to see that in their consistent voting against reauthorizing,” Flowers said.

Medicaid, funded by both the state and federal governments, provides health coverage for certain groups of low-income people. Expansion extended Medicaid coverage to nondisabled adults ages 19 to 64 with incomes up to 138% of the federal poverty level — about $20,800 a year for an individual in 2024.

The 2010 federal Affordable Care Act opened Medicaid to this new group of adults, starting in 2014. But a 2012 U.S. Supreme Court ruling said states could choose whether to adopt the change, and 40 have done so.

Republican state Rep. Ed Buttrey said he would sponsor a bill to reauthorize Medicaid expansion without an expiration date, but many GOP lawmakers remain unconvinced that expansion is needed, viewing it as a costly, unnecessary welfare program.

“I understand there are some pros to Medicaid expansion, but, as a conservative, I do have issues with — I guess I can’t get around it — socialized medicine,” said House Speaker Brandon Ler (R-Savage).

In September, representatives from a pair of conservative-funded think tanks made a case for ending Medicaid expansion, saying its enrollment and costs are bloated. The consulting firm Manatt, on the other hand, said more people have access to critical treatment because of Medicaid expansion.

At the least, it appears many Republicans want to require participants to work, pay premiums, or meet other conditions, if the program is to continue.

Premiums and work requirements are in Montana’s law right now. The Biden administration, though, nixed both, so they haven’t been in effect. Montana Republicans expect the incoming Trump administration to be more open to such provisions.

Democrats say Medicaid expansion has succeeded on many fronts: covering thousands of low-income workers, helping keep rural health care providers and hospitals afloat, and bringing hundreds of millions of federal dollars into Montana’s economy. The state pays 10% of the program’s costs, which totaled about $962.4 million in fiscal year 2024. The federal government picked up $870 million of that tab.

“With all that, it’s just stunning to me that there could be opposition,” Flowers said. “There is just no reason for us, collectively as a state, not to support this.”

Democrats will have their own expansion bill, brought by Rep. Mary Caferro of Helena. She said the bill would remove the work requirements and premiums, shine more light on the contracting activities of the state health department, and reopen some public assistance offices that have been closed. It also would make expansion permanent.

“We’re 10 years into this program,” said Rep. SJ Howell of Missoula, the Democratic vice chair of the House Human Services Committee, which debates health policy legislation. “I think that continuing a cycle of uncertainty for patients and providers doesn’t make sense.”

Legislators also see the expansion debate tying into other health care discussions.

Regier and Lenz said Montana’s nonprofit hospitals — strong supporters of expansion — have benefited greatly from the program and may need to give something back in return. One possibility: more government oversight of the “community benefits” that hospitals must provide to receive tax-exempt status.

They also noted that Montanans pay a fee for hospital stays to support the Medicaid program and that a fee on hospital outpatient revenue helps pay the costs of Medicaid expansion. Those fees and the resulting money raised for hospitals may merit review, they said.

Meanwhile, backers said Medicaid expansion underpins one of the governor’s major policy priorities, to improve the state’s behavioral health system. Gianforte has proposed spending up to $100 million over the next two years on 10 recommendations made by an advisory commission that reviewed the system for the past 18 months.

If Medicaid expansion ends, many adults would lose access to the mental health and addiction treatment system that Gianforte wants to improve, advocates said, while treatment providers would lose a significant source of revenue.

Money for the behavioral health changes would come, in part, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals during the budgeting process. Howell said Democrats want to look at whether the changes would use enough of the $300 million fund quickly enough and on the most pressing needs.

Meanwhile, Republicans said they’ll likely introduce bills on abortion — even though Montanans approved Constitutional Initiative 128 by a 58-42 margin in November. CI-128 said the right to an abortion cannot be “denied or burdened” except by a “compelling government interest achieved by the least restrictive means.”

“It’s not going to slow us down in our pro-life positions,” Ler said of CI-128.

At a minimum, GOP leaders said, some of CI-128’s terms should be defined.

“With a very poorly written ballot initiative like that, we need to say, ‘What does that abortion industry look like under CI-128 and what’s our role as a state?’” Regier said.

But state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Health, Welfare, and Safety Committee, said the CI-128 vote provided a strong mandate for the right of privacy.

Enacting restrictions would lead to “that slippery slope of what’s next, if we allow legislators to rule on what’s happening in the doctor’s office,” she said. “What kind of can of worms could be opened to other invasions of privacy?”

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Most recently, a Republican-led effort to make it more difficult to change that state’s constitution, which would have set a higher bar for an abortion rights ballot initiative this fall.

But the will of the electorate didn’t stop Republican lawmakers in one state, Montana, from passing a version of the anti-abortion proposal that voters rejected only months earlier. When Republican Gov. Greg Gianforte signed the bill in May, Montana became the only state to pass a law that directly contravened voters who said “no” to an anti-abortion ballot measure in 2022.

Last fall, 53% of Montana voters rejected a referendum that said care could not be denied to any infant or fetus that draws breath, has a heartbeat, or has voluntary muscle movement after an attempted abortion or any other delivery. Under the proposal, any health care provider violating the law would be committing a felony punishable by up to 20 years in prison.

But while Montana voters rejected the so-called “born-alive” measure, they also expanded big GOP majorities in the state legislature, which promptly passed a similar bill. The bill is different than the ballot initiative in two significant respects: It reduces, but doesn’t eliminate, the criminal penalties against providers; and it adds a provision that if a newborn is likely to die soon, the parents can choose to deny care and hold their child, providing “comfort care,” before it dies.

Lauren Wilson, a Missoula physician and president of the Montana Chapter of the American Academy of Pediatrics, said she’s glad the new language allowing parents to refuse medical care in those rare situations was included.

“We can live with the bill,” she said. “I don’t think it will land anyone in jail.”

However, she added, the bill, like the ballot initiative before it, is unnecessary and won’t change how health professionals practice medicine.

“This law is made to perpetuate a false narrative that there are babies out there who are going without care. It doesn’t happen,” Wilson said.

While Montana may be the only state where GOP lawmakers overruled voters on a specific abortion question this year, Republicans lawmakers in Kansas and Kentucky haven’t exactly backed off after being dealt ballot-measure defeats.

Last year, voters in those two states rejected constitutional amendments that would have said their respective constitutions contained no protection for abortion rights. Meanwhile, voters in California, Michigan, and Vermont approved referendums to constitutionally protect abortion access in those states.

The GOP-led legislatures in Kentucky and Kansas passed more anti-abortion bills this year, including, in Kansas, a “born-alive” bill similar to Montana’s.

Republican lawmakers in Kentucky introduced another constitutional amendment, to be placed on the ballot again, saying no constitutional right to abortion exists in the state. But this time, the proposal failed to make it out of the legislature.

The new Montana law passed on almost strictly party-line votes, with all but three of the legislature’s 102 Republicans voting for it and all 48 Democrats against.

Democratic state Sen. Andrea Olsen of Missoula said when it comes to abortion, Republican lawmakers clearly are ignoring a huge swath of their constituents.

“It’s our job to listen to the voters, their concerns, and solve problems, not use government as a tool for a political agenda of a few,” she said.

Supporters of the measure, sponsored by Rep. Kerri Seekins-Crowe, a Billings Republican, said some infants do survive attempted abortions. While such circumstances are extremely rare, those infants deserve protection in the law, they say.

The new law says any health care professional who “knowingly” denies care to a newborn commits a felony, although the maximum penalty was reduced from 20 years in prison to five years.

It also says violators can be subject to civil fines of at least $5,000, imposed by the state Department of Justice, and civil malpractice suits, with punitive damages.

The Montana referendum passed in 44 of the state’s 56 counties, most of which include districts represented by GOP lawmakers. It failed statewide on the strength of big opposing margins from the urban centers of Missoula, Bozeman, and Helena.

Jeff Laszloffy, the president of the Montana Family Foundation, which opposes abortion, testified in February that the lack of language protecting parents who refuse care to their dying infant is what caused the referendum to “barely fail” at the ballot box.

That allowed opponents to create the narrative “that children would be ripped from their parents’ arms that had no chance of survival anyway, and parents would not be able to spend those final moments with their child,” he said.

“This bill makes clear that that will never be the case,” Laszloffy added.

Clinics that provide abortions in Montana have said the new law doesn’t affect them, because infants would not be born during any procedure they perform. So far, no abortion rights group or individuals have stepped forward to challenge the law in court.

The conservative nonprofit Americans United for Life, which created similar to the Montana referendum, said have passed some form of “born-alive” infant protection.

The Montana Supreme Court upheld abortion access in 1999 under the state constitution’s right to privacy earlier this year. The state’s high court is expected to rule on a passed by Republicans during Montana’s 2021 legislative session.

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Beard, a Republican from the rural town of Elliston, ushered a bill through the GOP-controlled legislature this spring. The proposal would have moved more than 200 people off waiting lists for government-supported care and saved the state money by accessing more federal Medicaid money to cover their costs and the cost of those already in assisted living.

The bill had broad support from assisted living facility owners whose facilities eventually would accept more of these patients covered by Medicaid, the state-federal program that pays medical and other health-related bills for low-income and disabled people. In Montana, the federal government pays about 65% of the cost of most Medicaid-covered services, and the state pays for the rest.

But Republican Gov. Greg Gianforte vetoed the measure May 18, two weeks after the legislature adjourned. A post-session vote in June by Montana’s 150 lawmakers to override the veto failed by 10 votes.

Gianforte’s veto disappointed and mystified the bill’s supporters.

“I don’t see where there is any negative impact, financially for the state, for the residents, or to us as providers,” said Mike White, who co-owns seven assisted living facilities across Montana. “I thought, of all the bills out there, this would be the last one to get vetoed.”

Gianforte said the bill, by creating another Medicaid entitlement program, could have ended up costing the state much more in the long run. He also said it would have restricted the state’s ability to serve Medicaid-funded residents “in a community setting.”

Supporters of the bill said that the governor is simply wrong — and that Montana missed an opportunity to tackle a long-standing problem: the lengthy waiting lists for people on Medicaid who need assisted living or in-home care, to keep them out of more expensive nursing homes.

An analysis by said the bill would have saved the state $1 million during its first two years by using more federal money. Some supporters also pointed to the state’s $2.4 billion surplus, saying the state could certainly afford this small change to its Medicaid plan, if it ended up costing the state.

“This administration has shown that they don’t care about poor people, about people who are struggling,” said state Rep. Mary Caferro, a Democrat. “They simply don’t care, because we had the money to do it.”

The Gianforte administration insisted that there is no accurate way to estimate the long-term costs of placing assisted living under a Medicaid option called Community First Choice, and that doing so would complicate management of in-home and assisted living services.

would have required the state to place Medicaid funding for assisted living under Community First Choice starting in 2026, instead of a “waiver” program, where it’s been for many years.

States must ask the feds for Medicaid waivers to offer services or cover populations not covered under federal law. Like many other states, Montana asked for a waiver decades ago to cover nonmedical services that help keep older or disabled people out of nursing homes or other institutional settings. About 2,700 Montanans use these waiver-covered services each year, including about 900 in assisted living facilities.

But funding for Montana’s Big Sky Waiver program is capped by the legislature, so it has a waiting list for covered services. As of this spring, about 160 people who’d qualified for Medicaid coverage were on the waiting list for an assisted living spot.

An additional 150 people were waiting for other Medicaid services, such as in-home care that helps with daily chores like eating, dressing, and bathing. Those spots open only if lawmakers approve more funding or if a person getting the services dies or no longer qualifies for Medicaid.

Community First Choice, however, has no waiting list because it’s an entitlement, with no funding cap. A person who qualifies for Medicaid gets whatever services are covered under the program.

CFC was created as a state Medicaid option by the 2010 Affordable Care Act, in hopes of expanding coverage of services that help older and disabled people who have little income and few assets live independently, staying out of pricey facilities.

To encourage states to incorporate CFC into their Medicaid plans, the Affordable Care Act offered a higher federal match, of 6 additional percentage points.

Only nine states, however, have adopted CFC, and only three — Washington, Oregon, and California — have chosen to cover assisted living under the program.

Montana is one of the nine states that applied for the program, 11 years ago under Democratic Gov. Brian Schweitzer. But the state did not include assisted living as a covered service under CFC.

Rose Hughes, executive director of the Montana Health Care Association, which represents nursing homes and assisted living facilities, said states apparently worry that making these services an entitlement will increase their Medicaid budgets.

But she argued that expanding assisted living coverage under Medicaid saves states money because it can keep people out of more expensive nursing homes and, in some cases, costs less than in-home care.

Assisted living “is an extremely cost-effective service, and it’s one that seniors like,” Hughes said.

She also noted that anyone who qualifies for assisted living under CFC or the waiver is eligible for nursing home-level care.

“The day they get put on a waitlist, they could go to a nursing home, and the state would pay for that,” Hughes said.

And getting rid of the waiting list simply is the humane thing to do, bill supporters said.

The waiting list, managed by the state, rates people’s level of need and can seem incredibly arbitrary, bill supporters said. There are separate waiting lists for different locales; if you’re on the list in one town and move elsewhere, you must get on another waiting list.

“These systems are designed to protect people when they run out of resources. These people did their part, and we owe it to them,” said Michael Coe, director of operations for Caslen Living Centers, the company co-owned by White.

Beard eventually found her 82-year-old mother a spot at a Helena senior living facility that her mother pays for herself, without help from Medicaid.

Beard said the experience drove home the difficulty many Montanans face in finding such services if they can’t afford to pay.

She said she shares the concerns of her fellow conservatives about the state budget, but on this issue, she thinks paying for more assisted living slots is both fiscally sound and the right thing to do — and she’ll pursue it again in the 2025 legislature.

“This is a real need, and we’re not done with it,” Beard said. “I’m not giving up on this.”

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