Democratic Governor Steve Bullock had made expanding Medicaid to some 70,000 poor Montanans a priority since his 2012 election, and yet it seemed doomed.
In 2013 the bill failed by a single vote when a fellow Democrat mistakenly voted “no.” In 2015, the larger Republican majorities in the state House and Senate made passage seem like a fantasy. And yet in April, Montana became the 30th state to expand its Medicaid program.
In signing the bill, Bullock credited a “bipartisan group of legislators who put politics aside to make it a reality.” In reality it was a handful of Republicans who stood up to political pressure from national groups and their own party.
The bill was a compromise written by Republican Senator Ed Buttrey of Great Falls. With some changes, 12 of his fellow Republicans deemed his expansion bill worthy of backing and switched their previous “no” votes.
One of them was Dan Salomon.
“Dan is a friend, a hard-working, intelligent and effective legislator,” said Buttrey. “Our state and country would be better off with more statesmen like Representative Salomon.”
Salomon is a lot like the better off members of his district. A 58-year-old former dairyman, Salomon’s family settled in the Flathead Valley when the government opened up the reservation to white homesteaders in 1910. He was born at Saint Luke’s Hospital in Ronan, and studied agriculture at Montana State University. Now he grows wheat on 550 acres.
Salomon is a businessman. To him, covering the Medicaid gap -- those too poor to afford health care even in the Obamacare subsidized marketplace, but not poor enough to qualify for Medicaid – is a sound investment. He doesn’t approach his work in the legislature from a pure anti-tax ideological perspective like the Republicans who voted against expansion. Especially when he thinks it’ll save money in the long run.
Under the new Medicaid expansion law, the federal government will absorb 100 percent of expansion costs for the first few years of the program, with that number decreasing to no less than 90 percent afterward. The left-leaning Center for Budget and Policy Priorities calculates states will see at most a 2.8 percent increase in what they would have spent on Medicaid regardless from 2014 to 2022. And that doesn’t include the likely savings expected as preventative care reduces the frequency of costly emergency services among the newly insured.
According to Buttrey, Montana’s poorest citizens already get their healthcare for free, just in the most expensive ways like ER visits or becoming chronically ill before seeking care, and at the wrong time. All of which are problematic.
So Buttrey set out to find a solution.
“Republicans are problem solvers, most of us don’t want to just complain and stick our heads in the sand,” Buttrey said.
Montana’s percentage of uninsured residents is more comparable to Southern states that haven’t expanded Medicaid than its neighbors. It’s an island of uninsured in a sea of the relatively covered.
Supporters of the new law hope that is about to change.
Enrollment for Medicaid expansion in the state began on November 1, with coverage becoming effective on January 1, 2016.
According to Jon Ebelt with the state’s Department of Health and Human Services, as of August 15, 2015, 151,000, some 15 percent of Montana’s population, were uninsured. Ebelt says the new Medicaid expansion law is a chance to dramatically improve the health of the state, while also saving millions of tax dollars, creating jobs, and investing in our workforce.
For Buttrey, it is the last thing on that list that is the most vital. Buttrey is concerned one of the main reasons for the state’s slow economic growth is that too many people are either too unhealthy or addicted to be able to work.
“Unhealthy people become chronic and a burden long term to family, the state and social programs,” Buttrey said.
According to a 2013 report by the University of Montana Bureau of Business and Economic Research, the target population for Medicaid expansion is those uninsured individuals with incomes below 138 percent of the federal poverty level. Using BBER survey data, that’s 69,000 Montanans.
Many of them call Dan Salomon’s district in Lake County home. His district is one area of the state with high numbers of uninsured residents, and the numbers are rising.
Daniel Salomon represents House District 93 in northwest Montana’s Flathead Valley. His district covers the towns along U.S. Route 93 south of Flathead Lake, and includes the majority of Lake County’s population and the Flathead Indian Reservation. Caught between the economic poles of Glacier National Park to the north and Missoula’s University jobs to the south, it’s a poor, rural area in the shadow of the Mission Mountains.
In the 2013 legislative session, Salomon joined most other Republicans in voting against Medicaid expansion that would have covered all Montanans. This was between the passage of the Affordable Care Act in 2010 and the United States Supreme Court ruling it legal in June of 2015. Salomon doesn’t support Obamacare, and feels it’s an unconstitutional tax no matter what the Supreme Court says, but he’s still willing to work with it.
“It’s the law, it isn’t going away,” he said.
The 2015 compromise bill passed in April was more to his liking. Salomon thinks the governor’s original plan would have never passed, but the work Buttrey did before the session produced something he and the other 11 Republicans could get behind. The plan isn’t comprehensive, covering only Montanans stranded in the Medicaid gap.
Hardline conservatives in the Montana legislature oppose any Medicaid expansion, saying it will lead to higher taxes to cover the expense.
Just because he didn’t join the more ideological Republicans against expansion doesn’t mean Salomon is a progressive. He proudly tows the party line on issues like gun control (no thank you) and believes Montanans pay too much in federal taxes that don’t help them, whereas Medicaid expansion does.
“We’re getting it back for what it was meant for,” he said. “Get the money back, get people covered.”
Montanans still have to pay a health care premium to get coverage under Medicaid, and Salomon feels that personal responsibility for one’s well being is important.
“We’ll help you as much as we can but you’ll have to help yourself a little bit,” he said.
And his constituents need help.
Twenty-one percent of Lake County’s roughly 30,000 residents are uninsured, up 5 percent from 2014. Both the total number of uninsured and the increase are the highest in Western Montana, the only other counties above 20 percent found east of the continental divide. Like Lake County, their borders overlap with Indian reservations. The closest, Glacier County just across the Rocky Mountains, has the highest percentage of uninsured residents in the state at 27 percent, up 15 percent from the previous year, also the state high.
“Everybody knows somebody without healthcare,” Salomon said.
After the Recession and closure of the Plum Creek sawmill in Pablo in 2009, jobs dried up in Lake County, and with them employee health coverage. Salomon said although jobs in the Bakken Oil fields of North Dakota have brought down unemployment among his constituents, they don’t offer benefits, and it’s hard to keep the money in the community.
Another plus side to Medicaid expansion for Salomon is the money that will now be saved by local community hospitals. Hospitals like the one he was born in, St. Luke’s in Ronan.
One wall in the lobby of St. Luke’s Community Hospital in Ronan is floor to ceiling windows, with a view of Main St. and the snow-covered peaks of the Mission Mountains. Steve Todd, St. Luke’s CEO, says they hope to add a cancer treatment center on the floor above the lobby, so patients can look out onto the breathtakingly beautiful view while they sit through chemotherapy.
St. Luke’s is a community-owned hospital that serves a large rural area in Lake County, and it has a small town vibe. As Todd walks down the hallways, he greets by first name every employee he passes.
The hospital is equipped to provide cardiopulmonary services like stress echo testing and EKG’s, as well as laboratory and emergency room services. St. Luke’s also provides comprehensive pregnancy and childbirth services. Their New Beginning Birth Center is made up of three suites where labor, delivery and postpartum recovery all happen in a comfortable,homelike setting. Parents to be can wait for their new additions while comforted by amenities like a flat screen TV and a private bathroom. The bathroom includes a Jacuzzi bathtub bigger than some hotel hot tubs.
The building is 7-years-old and a beacon of modernity in a small Montana town. It has also faced the economic pressures of being a hospital in a community where 21 percent of people are uninsured. Without insurance, people will wait until a problem has become dire before seeking medical care. According to Todd, emergency room costs are the biggest financial burden to the hospital from the uninsured.
For example, a patient will come in to the emergency room with pneumonia from an untreated cold. Most times the ailments are preventable if caught early, yet by the time people see a doctor their condition has worsened.
It is Todd’s hope that when more people are insured they will be more likely to seek preventative medical care. In this way, Medicaid expansion can deliver a positive impact.
One problem both Todd and Salomon foresee with enrollment in Medicaid expansion in the state is the prevalence of that elusive Montana sense of pride. Rural farmers in the state especially have a tendency to not want to talk about or acknowledge when things aren’t going well.
“They don’t want to need help,” Todd said.
While some members of the community may be too tough to admit they need medical insurance, there are also many who have reached out to thank Salomon for voting yes. Salomon received hand-written notes and phone calls from the constituents expressing their gratitude. Sentiments that were not lost on Salomon.
“It was amazing,” he said, “surprisingly amazing.”
The majority of Salomon’s colleagues in the Republican Party likely don’t share his constituents’ enthusiasm. He should know by the March primary filing deadline how party bosses and Republican activists feel about his decision to cross party lines. Voting for expansion gives him a populist advantage against any Democratic challengers to his seat, but there’s always the risk of losing his party’s nomination.
Salomon doesn’t seem too worried about the compromise he made. Other Republicans in the state may not agree with Medicaid expansion as it stands now, but according to Salomon something needed to be done.
He wasn’t the only one who thought so. According to the Department of Health and Human Services, since expanded Medicaid registration opened in November there have already been more than 10,000 applicants out of the over 70,000 now eligible.
“If you just said no, what would that have gotcha?”