Governor Bullock's bill to expand Medicaid gets its first hearing in the state legislature on Friday. Watching closely will be Montana's hospitals.
To understand why, drop by an emergency room at one of Montana's bigger hospitals, like Benefis in Great Falls.
This ER serves about a quarter of the state's population. And 10 to 12 percent of Benefis' patients can't afford to pay their bills. Last year, that added up to $36 million in unpaid bills, or about three times the hospital's profit margin.
Kathie Avis, an administrator here, says that in states that have expanded Medicaid, the percentage of patients who can't pay their bills has dropped.
"More bills are getting paid, so if you look at Oregon, they've gone down considerably in terms of percentages, and the same thing in Washington."
Avis says that if more Montanans have Medicaid, traffic might actually go down at Benefis' emergency room. And that would be a good thing.
"When you look at the uninsured population, when they get sick, they usually can't afford to get primary care or preventative care, and even when they're sick they'll oftentimes stay home or delay seeing a physician. And they end up either in our ER for symptoms such as bronchitis or ear aches, or things that should really be taken care of in a physician's office in a lower cost setting."
Some people without insurance even refuse ambulance rides to the emergency room because they know they'll get hit with a big bill they can't afford. 32-year-old Great Falls resident Jake Sorich has done that.
"When you think of, how am I going to afford this? Versus, I need this to stay healthy, or to stay alive, that's kind of a bad choice (laughs)."
Sorich was born with diabetes. Last June he quit his newspaper job to start his own business, the entertainment news website bigskystatebuzz.com. Sorich says, with newspapers continuing to downsize, it seemed like a good time start working for himself. Especially, he says, because giving up his job wouldn't necessarily mean going without health insurance. He'd be able to get an Affordable Care Act subsidy to help him pay for coverage when he was starting up and his income was low. Or at least that's what he thought.
"It was really kind of a rude awakening," said Sorich.
It turns out, Sorich couldn't get one of the subsidies, because his income was too low. People have to make about a $1,000 a month or more to get a subsidy. He wasn't making enough as a self employed writer.
Originally, the health care law said people making less than $11,700 a year would get expanded Medicaid. But then the Supreme Court ruled that states don't have to expand Medicaid if they didn't want to. Montana hasn't, and Sorich was out of luck.
"It's a tough sled, you know, saying, you don't make enough to qualify for health care is kind of ludicrous," Sorich said.
The state of Montana estimates that there are about 70,000 people in the state who'd benefit from expanded Medicaid, and Democratic Governor Steve Bullock is pushing hard to make expansion happen.
In January the Governor held a press conference introducing a Medicaid expansion bill he hopes will be more palatable to lawmakers than the one that failed in the 2013 legislature.
"Today we're taking an important step to address this injustice. As we officially bring forward legislation to implement the Healthy Montana Plan," Bullock said when introducing his proposal.
And just like in 2013, Governor Bullock's plan faces significant opposition from Republicans, says Stevensville Senator Fred Thomas.
"When talking to most Republicans they're not interested in what is called Medicaid expansion, which the Governor is proposing we do," says Thomas.
Republicans oppose Medicaid expansion on philosophical and fiscal grounds. They oppose growing government programs on principal. And they say neither the state nor federal government can afford to add people to Medicaid. Medicaid is jointly funded by the state and Washington, with the federal government picking up most of the tab.
But Senator Thomas says his party isn't opposed to any Medicaid expansion.
"What we're willing to do, and what we want to do with Medicaid in Montana, is we want to add some people to it, about 10,000 to 15,000 Montanans to Medicaid."
Thomas says expanded Medicaid should be limited to low income parents, the blind and the working disabled.
"People that are working, but able-bodied and no kids? It's hard to put them in the same boat as somebody that's disabled, and say we're gonna give you the same thing that we're giving to this disabled person. You have the ability to up your hours and do what you can to get above the federal poverty level which is just $11,760, and then get insurance on the exchange. I mean, that's a reasonable solution for that individual."
Back in Great Falls, that's exactly what Jake Sorich has done. He's taken on couple of part time jobs in addition to starting his own business, just so he can afford health insurance. His Affordable Care Act subsidy means he pays $32 a month for coverage.
"It's definitely a balancing act, and a juggling thing, and it definitely would be easier if I just could focus on my one thing," Sorich said.
At Benefis hospital in Great Falls, administrators are continuing to support Governor Bullock's Medicaid expansion, and not the smaller one Republicans like Senator Thomas advocate. They point out that Montanans already have the option to go find jobs paying about a thousand dollars a month to get subsidized health insurance. But 10 to 12 percent of the people who come through the hospital's doors remain uninsured. Vice President Amy Beames says that translates into higher bills for people who do have insurance.
"From a hospital perspective, we're interested in this because there's cost shifting that occurs. In order for providers to stay in business, those who are privately insured pick up what we call the hidden tax associated with the health costs for those that don't have insurance."
The Republican Bill to partially expand Medicaid in Montana has had one hearing in a House committee so far. It's part of a package of bills the party is calling it's “Big Sky Health” plan. Governor Bullock's bill for full Medicaid expansion gets its first hearing in the House Human Services Committee late Friday afternoon.