Christina Macintosh, Billings Gazette
Just after Medicaid redetermination has come to a close, Billings institutions in support of renewing Medicaid expansion, which expires in 2025, are gearing up to advocate for its renewal in the state's next legislative session.
Local proponents argue that the program benefits the Yellowstone County community as a whole by increasing access to preventative mental health resources and funding programs that relieve some of the pressure on law enforcement and emergency services.
City Council’s Legislative and Local Affairs Committee, which decides which policies the city will lobby for at the state level, discussed in their last meeting how Medicaid is integral to funding the city's new crisis response unit, which responds to mental health crises and helps free up law enforcement for public safety issues. Official support for reauthorizing expansion will have to be voted on by the entire council.
Healthcare providers argue that expansion leads to additional savings by helping to prevent crises altogether, by giving more Yellowstone County residents access to preventative mental health and substance abuse help. The boards of Billings Clinic and RiverStone Health have passed resolutions in support of Medicaid expansion. St. Vincent Regional Hospital leadership also supports expansion.
Healthcare providers argue that Medicaid expansion further benefits the community as a whole by giving providers a base of covered patients that they can bill for services, as opposed to providing uncompensated emergency services, as they face ongoing financial challenges wrought by Medicaid redetermination and the fallout of the Covid pandemic.
Medicaid or a mill?
City Council supports expansion because the crisis response units, which respond to mental health crises, rely on Medicaid reimbursement to compensate the unit’s mental health services provided by the Rimrock Foundation. If additional people are dropped from Medicaid, the team will not be reimbursed for as many calls.
“We can’t bill them for services if they’re not covered,” said Jessica Fust, a city official.
This could spell the end of the program or force the city to rely on local funds, and thus taxes, to keep it running.
The city introduced crisis response units to relieve law enforcement of the burden of responding to mental health crises. Still, in the recent budget cycle, law enforcement has complained of being stretched thin.
Just last month, when next year’s budget was finalized, City Council awarded BPD and BFD funding to create 23 new positions. These positions came at the price of cutting corners elsewhere, such as parks funding.
“Let’s just call it what it is, if the federal government or the state or Medicaid doesn’t fund any of this stuff, we send police officers, firefighters and ambulances,” City Administrator Chris Kukulski said at last month’s Legislative and Local Affairs Committee meeting.
“Because of its work in mental health and behavioral health, a more effective, less costly way to provide the service is to make it reimbursable through the Medicaid system and therefore we don’t have to raise taxes as much at the local level to fund it,” he continued.
Between January and March, just under 47% of crisis response unit clients were on Medicaid. This is just enough to make the program financially feasible, according to Zack Terakedis, executive director of Substance Abuse Connect, a local organization that helps facilitate the program.
If Medicaid expansion were to be repealed and fewer clients were to be insured, the program may need another funding source.
The prospect of uncompensated care also threatens the city’s healthcare providers. Montana hospitals reported $236 million in uncompensated care costs in 2022, down from $390 million in 2015, before Medicaid expansion, according to the Montana Healthcare Foundation.
The Billings Clinic Board’s resolution in favor of reauthorizing expansion said that the hospital has remained financially viable over the past few years because of a 63.5% reduction in uninsured patient volumes since Medicaid expansion took effect.
Medicaid expansion decreased the number of uninsured Yellowstone County residents by 54%, according to the hospital.
Medicaid payments account for nearly 20% of the hospital’s revenue, helping to support the hospital for the entire community. The resolution says that the hospital is “facing unprecedented financial pressures” and cannot afford to lose more revenue.
Mental health
Besides mobile crisis response, expansion proponents argue that it helps preserve access to mental health services, a purported priority for the state, which formed a commission last year to allocate $300 million to bolster the state’s mental health infrastructure.
Last year’s Community Health Needs Assessment, administered by a partnership of Billings Clinic, St.
Vincent Healthcare and RiverStone Health, found mental health and substance abuse to be the community’s biggest issues. Over 81% of respondents reported mental health as a major problem in the community and 74.4% reported substance abuse as such.
Just over 20% of Yellowstone County residents surveyed described their mental health as “fair” or “poor,” which has increased with each assessment since the first in 2005. One-third of respondents reported having been diagnosed with a depressive disorder, another record high.
Medicaid expansion covered mental health services for 7,648 patients and substance abuse treatment for 2,150 patients in Yellowstone County last year, according to Billings Clinic.
Mental health is the number one reason for visits to the Billings Clinic emergency department, with 3,802 visits last year accounting for 7.5% percent of total visits, according to Zach Benoit, the hospital’s community relations manager.
Emergency visits related to mental health and substance use disorder of Medicaid expansion enrollees in Montana decreased with each year of coverage, according to a 2024 report by the Montana Healthcare Foundation.
Medicaid expansion enrollees in their third year of coverage reported 8% fewer visits than those in their first year of coverage for mental health and 9% fewer visits for substance use disorder.
“Medicaid expansion has reduced barriers for Montanans to have access to mental health care, primary care, medications, specialty services, emergency services, dental care, substance abuse treatment and many other services they may not otherwise be able to afford,” Benoit said.
Without insurance, delaying healthcare needs leads to poorer outcomes and higher costs, which may not be compensated due to patients’ inability to pay.
Healthcare and the economy
Healthcare providers argue that Medicaid expansion supports jobs in the healthcare sector and the economy overall. Healthcare and social assistance is the county’s biggest industry, according to the state’s Department of Labor and Industry.
RiverStone Health laid off 41 employees in May, citing decreased patient visits and a $3.2 million budget shortfall due to Medicaid unwinding. Billings Clinic Bozeman laid off 15 employees the same month.
Medicaid expansion has supported 1,583 jobs, $113.6 million in personal income and $262.5 million in local economic activity in Yellowstone County alone, according to Billings Clinic.
Advocates also argue that Medicaid is financially beneficial for the state. The federal government pays for 80% of Medicaid spending and 90% of expansion spending. As an incentive to get states to expand Medicaid, the federal government pays a higher percentage of traditional Medicaid if states adopt expansion.
The savings of expansion offset 44-68% of the state’s expansion costs, according to a presentation by economist Dr. Bryce Ward prepared for an interim legislative committee. It also leads to state savings on substance abuse and mental health spending. Studies have also shown that Medicaid expansion reduces crime and recidivism, likely by providing for mental health and substance abuse treatment, according to Ward.
What comes next
The future of Medicaid in Montana is anything but certain, hence the early advocacy effort. In 2019, the bill to reauthorize expansion initially failed in the senate before narrowly passing.
In the house, all 41 Democrats voted in favor, along with 20 Republicans. The other 37 Republicans opposed the bill. In the senate, all 20 Democrats voted in favor; eight Republicans supported the bill and 22 opposed it.
If the legislature were to vote to not reauthorize Medicaid next year, Montana would join just 10 other states that have not expanded Medicaid. It would join Wyoming as the only state in the region to not have Medicaid expansion.
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