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Bureaucrats have referred to what is happening to Medicaid enrollment as “redetermination,” “disenrollment,” and “unwinding,” but what it means in Montana is that about 42% of adults and 35% of children once eligible for Medicaid are suddenly without coverage. The numbers are close to double what earlier independent estimates expected for the federally mandated process of reevaluating Medicaid enrollment after the pandemic. These results, coupled with widespread reports of a sluggish process used by the state, have caused critics to charge that the cancellations were deliberate.

“I was always concerned about the cumbersome process the state set up, and now that I see the total numbers of people that have been removed, I almost think it was a purge as opposed to a genuine effort to help people on Medicaid,” Kim Gillan said in an interview. Gillan is a former Democratic state legislator but also served as a regional director of the U.S. Department of Health and Human Services in the Obama Administration and has since kept close tabs on the state’s health care system.

During the pandemic, federal rules for Medicaid placed a moratorium on cancellations when people most needed health care. With the health emergency over, though, the federal government told states to review the Medicaid rolls to trim those no longer eligible, a process Montana started in April of 2023. In January, Democratic legislators filed an open records request with the state Department of Public Health and Human Services, which administers Medicaid in Montana. The state delivered a report citing numbers as of March 4 that confirmed the extensive cuts from the Medicaid rolls and the critics’ long-standing suspicions.

Gillan said the numbers immediately triggered alarm because of earlier forecasts by two independent national watchdog groups. The Kaiser Family Foundation estimated unwinding would cut about 60,000 people from the rolls, while a separate study by George Washington University placed the number at 71,000. The final tally of 112,663 people “terminated,” however, was close to double that amount, and that number could well increase. About 15% of the results are still listed as “pending,” and some of those people likely will have their insurance canceled. 

Both Gillan and Mary Caferro, a current Democratic state legislator who has closely followed Medicaid issues in the state for more than 20 years, believe the heavy cuts were the result of deliberate sabotage driven by Gov. Greg Gianforte’s opposition to Medicaid. The legislators charge that the state designed a process loaded with stumbling blocks meant to discourage applicants.

“What they could have done (instead) was to help people,” said Caferro. “Number one, they (state DPHHS) didn’t prepare. Number two, they didn’t put any of the state-of-the-art tools in place and three, they didn’t take the federal government up on offers to help.”

She said the state used only Postal Service mail to notify applicants, some of whom are homeless or move frequently. The state also sent a form that was too long and failed to conduct any sort of direct follow-up or outreach through other means such as personal contact and social media, all steps other states have taken. Applicants could call the state to reapply or ask questions, but reportedly faced wait times on phone calls of up to six hours.

Caferro said she personally helped one foster father of four with the application process, assisting him in filling out the lengthy form. His application was denied and, in the end, he simply gave up rather than deal with the cumbersome process.

The cancellation of Medicaid insurance is particularly worrisome in Montana because about two-thirds of people on the program are rural residents. Earlier efforts to expand Medicaid coverage in the state have been bolstered by the support of rural Republican legislators simply because without Medicare and Medicaid all rural residents —- not just low-income people —- are threatened. Rural hospitals, clinics and nursing homes depend on Medicaid income to keep their doors open. Eastern Montana, especially, is sparsely populated, meaning if a clinic or nursing home closes in a given town, the next one may be two or three hours’ driving distance away. 

The Montana Budget and Policy Center cites a program of Medicaid expansion under former Democratic Gov. Steve Bullock as responsible for the state’s unusual success in this matter: “While 136 rural hospitals closed nationwide between 2010 and 2021 (74 percent of those were in non-expansion states), no rural hospitals have closed in Montana since the beginning of Medicaid expansion,” a report from the group says.

The rationale for the current administration’s foot-dragging on this issue is not strictly fiscal. Medicaid costs are about 90% covered by federal reimbursements, meaning the program is one way to funnel federal money into rural communities with minimal costs to the state. But the motives do appear to be related more to Republican ideology than to money. For instance, Axios reported that 60% of children who lost Medicaid coverage nationwide last year came from just nine states, all of them governed by Republicans.

The state DPHHS director’s office did not respond to an emailed request for comment on the Democrats’ charges or the numbers.

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