Back in 2015, being a Montana Republican meant despising Obamacare — and your loathing of it better have been a preexisting condition.
House Speaker Austin Knudsen qualified. He voted against the state’s decision to expand Medicaid coverage under the Affordable Care Act in 2015. When he ran for reelection last year, he pilloried Obamacare, saying he didn’t want Congress to “delay the removal of this ill-conceived disaster of a law.”
That is now a distinct possibility, with Congress moving this week to begin the process of repeal.
But this has become a conundrum for Republican state lawmakers in GOP-dominated legislatures that expressed bitter opposition to the healthcare reform law but nonetheless took its federal Medicaid expansion money.
Though President-elect Donald Trump has said the law won’t be scuttled without a replacement “very quickly,” many state legislatures find themselves having to plan budgets without knowing whether they’ll be stuck paying to keep their poorest citizens insured.
Medicaid was expanded under the law in 31 states, but only seven of them were states with Democratic majorities who embraced federal healthcare reform. Ohio Gov. John Kasich, a Republican whose state added 700,000 to the health insurance rolls, told reporters last week: “I just want to know what’s going to happen to all those people who find themselves out in the cold.”
GOP lawmakers in North Dakota and Nevada have expressed similar worries.
Montana is in a particularly precarious position. The state is required by constitution to balance its budget based on projected revenues, but its Legislature meets only every other year — meaning lawmakers who began their session this month have to peer two years into the future at the unpredictable landscape of federal healthcare law.
Obamacare provided health insurance to thousands of Montanans who formerly didn’t have it; now, even Republicans worry that Congress may scuttle the law without funding an alternative.
“I still don’t think it’s realistic to say ‘Well, we’re going to cover an additional 60,000 to 70,000 people but if the federal government takes the money away, we’re simply going to jerk the rug from underneath those people,’” Knudsen said.
Sitting in his office on a cold, snowy afternoon the first week into the legislative session, he leaned forward confidentially.
“We can’t afford it.”
Minority Democrats in Montana tried twice to expand Medicaid coverage during implementation of the federal healthcare law. A slim Republican majority beat it back in 2013 but narrowly succeeded two years later with a plan to offer Medicaid coverage to all adults with incomes near the poverty level.
Rep. Rob Cook, a burly man who played running back in high school, carried the bill as the Republican sponsor and was intent on getting it to the goal line.
Cook said after he cast his vote in favor of the expansion and it passed 54-42, he looked around at the majority of his fellow Republicans on the House floor.
“It was 42 faces of hate,” he said.
Yet the program proved popular in the sparsely-populated state, with twice the number of people expected signing up by July 2016. There are 61,233 on the program now.
Republicans in Montana, as in most frontier states, often share with their constituents a high degree of mistrust and distaste for the federal government — an attitude that carries into fights over public lands, gun rights and, in recent years, Obamacare.
“Washington, D.C., is seen as far away, distant, removed and not in touch with what life is like here in Montana,” said Robert Saldin, associate professor of political science at the University of Montana. “The popular image of the bureaucrat in some cubicle making critical decisions that affect life here in Montana without any knowledge, or having been here, or how policies affect people on the ground here, is the kind of image at work within the Republican Party here.”
But with droves of outsiders moving into university towns like Missoula and Bozeman, the state isn’t entirely intolerant of Democrats. As recently as 2009, the House was split 50-50; last year, they were at 61. Republicans hold a four-seat edge in the Senate. Gov. Steve Bullock is the second consecutive Democrat to lead the state.
Senate President Scott Sales, a Republican who voted against Medicaid expansion, said he’s sympathetic to those who are now getting health care for the first time and has heard health success stories because of the law.
But Sales said the state can’t afford to keep the program going on its own. Montana paid just about $5 million for its share of the program, while the federal government kicked in $153.6 million for six months in fiscal year 2016, according to the Legislative Fiscal Division.
The state projects its cost over the next two fiscal years to rise to about $70 million, with $847 million in federal funding.
Montana doesn’t have a lot of options. Lower-than-expected oil and corporate tax revenues left the state $142 million short of expectations in the 2016 fiscal year, based on a two-year budget of $12.8 billion.Sales said most of those getting health insurance under the Medicaid expansion are capable of working and getting private insurance.
“The best thing we could possibly do for people — the best healthcare system — is a good job,” Sales said. “They need to take ownership for themselves. ... There is no constitutional guarantee to healthcare. If there is one, I’d love to have someone show it to me.”
To appease Montana Republicans when the expansion law was passed, a sunset clause put it up for renewal in 2019. But Bullock said stripping recipients of healthcare without a plan would be irresponsible.
Governing the fractious state, Bullock, with his frequent vetoes, has come to be known as the “goalie governor.” But he said lawmakers of all stripes have heard the stories about people getting healthcare for the first time.
One man wrote the governor an email about how the new insurance had allowed him to see a doctor and get treatment for a potentially fatal adrenal crisis.
“You saved my life on Feb. 10,” he wrote.
While the debate over Obamacare is taking place in Washington, Bullock said, it is states that are on the front lines, and state lawmakers who will have to figure out what to do until Congress finds a solution.
“Doubtless if the ground substantially shifts, we’ll hear from people a lot more than the folks in Washington, D.C., will hear from them,” Bullock said. “Because we also see them in our churches, in our communities on our streets.”
Cook agreed, saying congressional Republicans didn't have any real stakes in the process while President Obama was in power.
“The easiest vote in any legislature is a no vote [for something] you know is going to pass,” he said. “I think Republicans have been negligent at the federal level in not trying to make the program work. It’s been extraordinarily bad behavior and it’s not what you get elected to do.”