(air whooshes) - [Anna] Coming up next on "IMPACT," healthcare coverage for roughly 75,000 Montanans is at stake as lawmakers debate the future of Medicaid expansion.

- When you look at total revenue versus total cost, it's not keeping up.

(air whooshes) - [Anna] And as if the tension over tough bills like Medicaid expansion wasn't enough, Republican infighting is adding a layer of fractious debate that spilled out onto the Senate floor.

- You played some shenanigans, you played some games.

Way to go!

- I'm embarrassed to be in this chamber at this moment.

It's broken.

We're broken.

- [Anna] A look at how Republican alliances and divisions can make or break legislation in Helena.

(air whooshes) Those stories next on "IMPACT."

- [Announcer] Production of "IMPACT" is made possible with support from the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans, and viewers like you who are friends of Montana PBS.

Thank you.

(air whooshes) - Welcome to "IMPACT."

I'm Anna Rau.

Montana's Medicaid expansion, primarily funded by the federal government, is set to expire this summer if state lawmakers don't act to extend the program.

As Montana PBS's Stan Parker reports, the fight is pitting Montana's healthcare industry against fiscal conservatives in the Senate.

(air whooshes) - [Stan] On a cold day in January, a group of Montanans gathered at the Capitol steps to voice their support for continuing Medicaid expansion in Montana.

Lawmakers last renewed the program in 2019, and unless they act again, healthcare coverage for roughly 75,000 Montanans will expire at the end of June.

- Medicaid expansion has worked for Montana.

Do we agree to that?

- Yeah!

- All right.

- [Stan] Although Medicaid expansion has broad support, Republican leaders in the Senate are concerned about the cost to the federal government.

- The United States is moving in an unsustainable pattern with 36.4 trillion in debt.

To get that back into balance is extremely difficult, and the longer it goes on, the more difficult it becomes.

- [Stan] Several Montana nonprofits helped organize this rally, including Big Sky 55+, an outfit where Kristen Stewart works as a part-time organizer.

- This effects of a lot of people in Montana, often working people, people who are caregivers like myself.

- [Stan] Kristen is part of the demographic that Medicaid expansion mainly provides coverage for, able-bodied adults of working age whose incomes, for whatever reason, (people cheering) fall below a certain threshold.

In her case, full-time employment would mean sacrificing time spent as a caregiver.

- Initially, when I qualified for Medicaid, I had recently moved back to Billings.

I actually left a job that had healthcare, but there was no flexibility.

(chuckles) At the time, my grandfather was still alive, and we had two to three errands a week in the middle of the day that needed to be driven to.

- [Stan] Medicaid expansion is distinct from standard Medicaid, which covers specific groups like children, adults with disabilities, and expecting mothers.

Expansion covers working age adults who make up to 38% more than the federal poverty level, or FPL.

The FPL varies by family size.

So, for example, a single parent with two kids would be covered by Medicaid expansion if they make up to about $37,000 this year.

Here's where Medicaid expansion dovetails with other programs.

If that parent made less than 25% of the FPL, they'd be covered by standard Medicaid.

And if they make more than the FPL, they can get help from the federal government to buy private insurance on the marketplace, up to a point.

But between 25% and 100% FPL leaves a coverage gap that Medicaid expansion fills.

If you find the difference between standard Medicaid and Medicaid expansion confusing, you're not the only one.

- Many emails I get are actually writing in about Medicaid because they're concerned about elderly people, infirmed, mentally ill, or disabled people losing their benefits, and that's all Medicaid, and so no one in the legislature is talking about diminishing benefits for those who have true needs, the mentally ill, disabled, infirmed, elderly, pregnant moms, et cetera.

- [Stan] Even Senator Carl Glimm, who introduced a bill to phase out Medicaid expansion, got it wrong in committee.

- So, Medicaid expansion is for able-bodied adults without kids.

- [Stan] It's a point we cleared up in our interview.

- They would, if you have kids, you would qualify under traditional Medicaid.

- But only if you're making less than 25% of the federal poverty level.

- I would have to check on that.

- [Stan] We took a few minutes to get on the same page and confirm that, yes, the Medicaid expansion sunset does affect many Montanans with children at home.

- Yeah.

Yep, you're right.

25%, under 25%, so- - [Stan] Five days after that interview, Glimm's proposal stalled when it failed to pass a floor vote.

This could be a sign that the Senate will look favorably upon a House bill to lift the sunset and keep Medicaid expansion in place.

That bill recently passed its final vote in the House and is now in the Senate's hands.

That bill was introduced by Republican Ed Buttrey of Great Falls, who also carried the Medicaid expansion bills in past sessions.

- We did something really special for the people of Montana in 2015 and again in 2019.

We created a system that, unlike in other states, actually moves people out of poverty and onto the road of success.

Our system puts healthcare back in the doctors' offices and out of the emergency rooms.

Our system has enhanced the pool of workers available to our businesses, and I'm happy to say we have ensured the future of our rural healthcare systems, all of this while providing a positive savings to our general fund and the taxpayers of Montana.

- [Stan] A steady parade of voices from Montana's healthcare industry, tribal nations, and business community showed up to support the bill.

- You're improving the quality of services available to Montanans that otherwise might not be able to afford health insurance.

- The ability for me to hire behavioral health providers alone, this is just for behavior health, has greatly improved the mental health of our reservation.

I'm not sure where we would be without Medicaid expansion.

- I'd be concerned that the loss of this program would threaten the future of Northern Montana Hospital and many other critical access hospitals across the state.

- [Stan] Among those supporting permanent expansion of Medicaid was Billings Clinic's CEO, Clint Seger, who says when people don't have insurance, they sometimes put off care until they end up in the emergency room.

- Delayed care is always more expensive, and I worry about patients having to receive their care largely through the emergency room because they don't have access to basic healthcare, and so they delay, things get delayed until it's critical.

- [Stan] The healthcare community speaking as a united front is not persuasive to Senate Republican leadership, including Majority Leader Tom McGillvray of Billings.

- There's one person that never shows up at hearings.

The person that's working 40, 60, 80 hours a week and paying taxes.

- [Stan] Despite data showing expansion having a positive impact for Montana's economy, he worries about the federal budget.

Medicaid expansion spending in the state was about $1 billion in 2023, and the federal government pays 90% of that.

For standard Medicaid, the feds pay around 62%.

- You know, every country in the history of the world that's ever failed because of debt problems, Germany, Rome, ancient Israel, et cetera, Argentina, they inflate.

But for the big risk is for our grandchildren, my grandchildren, your children, because when you are broke as a nation, when you are financially weak as a nation, you are susceptible to foreign adversaries who want to take advantage of you.

So it's our grandchildren and our children that have to fight wars for their freedoms and the liberties and the financial ability to sustain ourself that we, that's what's at stake.

- [Stan] And Senator Glimm argues there's a risk in leaning so heavily on the federal government.

- It's crazy for us to think that the status quo is gonna be the same, because the low-hanging fruit for real dollar change in the federal budget comes in to some of these programs, and Medicaid expansion is a huge one.

I think we're better off if we get those people working into a working job.

We've got tons of employers looking for help.

You can't go anywhere without seeing Help Wanted signs in the state of Montana.

And if we put those people to work, it's better for everybody.

- [Stan] Stats from the Department of Labor show the majority of Medicaid expansion enrollees are already in the workforce, and many of those that aren't have health issues, have a caregiving role in the family, or going to school.

And Buttrey argues Montana's expansion program has shown itself to be a temporary measure for many people as they get back on their feet.

- The average time for an individual in the program, notwithstanding the public health emergency, is 22 months.

This is a fact, and it completely debunks the myth that once somebody gets on this program, they never leave.

Furthermore, independent data clearly shows that when our economy is good, our enrollment numbers drop.

And this is how we design the program, to get people healthy, get them jobs or better jobs, and to be less reliant on social services, and to a place where they can rely less on state and federal programs and they can rely more on themselves.

- [Stan] Data also show that Medicaid expansion has done a lot to bring down the number of uninsured Montanans.

Jayme Hernandez, a resource navigator at RiverStone Health in Billings, says she worries the uninsured rate will rise without renewing expansion.

And although the healthcare marketplace will be an option for some, she says it's not always a good one.

- Lower income families that really fall within these expanded categories, I don't feel like the marketplace is going to be a good best next option for them.

And I say that because from helping people with enrollment with that, there are a lot of options on the marketplace, however, they can be really specific to what medical facility you attend, and that can kind of lock you into some services.

And then, a lot of the plans have really, really high deductibles on them as well.

And so even if maybe someone would find a cost plan that they felt like they could afford, they may not be able to utilize it because they may never meet the deductible of the plan.

- [Stan] For folks like Kristen Stewart and her grandmother, Frances, the flexibility provided by Medicaid expansion is a big help.

- I don't know how we would've gotten around without her.

She's just been a godsend for me.

She's been a lot of help and I don't know what I would've done without her.

- I don't know everybody's situation, everybody's situation is different.

So it's not like we're not without compassion here.

But, again, you have to deal with the problem of scarcity in this country.

Do you wanna destroy everybody's livelihood because you're removing programs that are simply unaffordable, or do you wanna make choices?

- [Stan] For Dr. Seger at Billings Clinic, he doesn't dismiss the fiscal policy concerns.

- I wouldn't say that those are not concerns that should be addressed, and that's outside of my pay grade to address some of those big, big questions, but I think whatever system or however we do this, what's important is to make sure that patients have and people have access to care and we deliver, we can deliver high-quality care, no matter where you live.

- [Stan] For "IMPACT," I'm Stan Parker.

- Montana is one of 40 states with a Medicaid expansion, along with the District of Columbia.

The 2010 Affordable Care Act originally mandated the program nationwide, but the US Supreme Court ruled that lawmakers in each state should decide whether to expand eligibility.

Republicans already know they're divided on Medicaid expansion, but that's not the only issue this session where we've seen the majority party clash.

As Montana PBS's Breanna McCabe reports, lawmakers were less than an hour into the new session when Republicans started scuffling.

(air whooshes) - [Breanna] In Helena, there's a house where the rules do apply.

- The rules are pretty easy and simple.

It's like the first thing we do.

- [Breanna] And that first day in front of family is supposed to be about the ceremony.

- The House was particularly boring, which is normal.

(gavel banging) - [Breanna] But 21 minutes into this Senate session, the rules became a sudden point of contention.

- I have seen disagreements over the rules.

I've never seen it explode on the floor like that.

- Senator Flowers, for what purpose do you rise?

- [Breanna] It wasn't over a bill, but over committee assignments, with eight senators supposed to serve on a new committee this session.

- We haven't needed one.

- [Breanna] An assignment they say sidelined them from the Senate's bigger, more important committees.

- Am I the only person that thinks it's odd to have- - Why would you have eight or nine of your senators, there's only 50 of us, (chuckles) so 18% of us, being put on a committee that doesn't have work?

- We were dissatisfied, there were some Republicans that were dissatisfied, and out of that came an agreement to offer this alternative approach.

And it reassigned some- - Democratic Minority Leader Pat Flowers asked for new assignments right before the existing ones were set to go into effect.

- Typically, the majority leader and the minority leader concur, or at least let each other know that emotion's coming.

So it's kind of a breach of, you know, traditional protocol and the honor system that we kind of go by here in the legislature.

- Day two may not have worked, day three may not have worked.

It really had to happen on day one.

- Senator Ellsworth.

- I'm in complete support of this motion.

- [Breanna] Last year's Senate president, Republican Jason Ellsworth, had been assigned as chair of the new committee.

- So, of course I'm gonna support a motion that doesn't sideline me so I can represent my constituents.

- All those in favor vote aye.

(electronic beeping) - [Breanna] Ultimately, Ellsworth and the other Republicans assigned to the committee voted with Democrats in support of new assignments.

- Every member voted.

- Four other Republicans sympathized with the cause and gave it enough votes to pass.

- We got it outta the road right away, (chuckles) and much better then than to have it faster.

- Everything's gonna go to heck.

- [Breanna] But that wound would deepen in the weeks to come- - Today is a very dark day.

- [Breanna] As those on the other side of the vote- - It took us all by surprise.

- [Breanna] Worried they'd lost their power.

- The state of Montana elected more Republicans than Democrats to this House!

We know what happened.

Day one, 15 minutes into it, all that changed.

- Threw everything into a chaos, basically, and there was nine of 'em, nine Republicans that voted with the Democrats to do this.

And, you know, they've been labeled the Nasty Nine.

- [Breanna] Senator Barry Usher reactivated his decade-dormant X account to express his disgust.

- They betrayed the Republican Party and they betrayed the Senate and the precedents and the, you know, the institution of the Montana State Senate.

I mean, it's broken, we're broken.

- There was a reshuffling of the deck, which to me was very, um- - [Breanna] Senate President Matt Regier struggled to find the words.

- What would be the word?

Dismissive of the caucus.

- [Breanna] Republicans hold a majority in both chambers this session.

In the 50-seat Senate where 26 votes are needed for something to pass, they fill 32 seats.

And in the 100-seat House of Representatives, Republicans occupy 58 seats to the Democrats' 42.

But Speaker of the House Brandon Ler says even when they hold the bulk of the seats, Republicans don't always vote as a block.

- I mean, you look last session and we had the super majority and we didn't get a lot of things through that we wanted through.

(chuckles) So, I mean, there's no leniency there.

In fact, I mean, being in the majority party is tougher because you're expected to do things.

- [Breanna] A divided majority party tends to be tradition no matter who's in charge.

- It's not like this is a new thing for Republicans.

If we went back 30 years ago and watched when the Democrats ran the legislature, you would see those same divisions.

There were always, you know, a more liberal wing and a more moderate wing in the Democratic Party and they had divisions in those days.

- [Breanna] But it isn't all adversary.

Legislators align at lunchtime, plans hatch in the hallways and develop behind closed doors.

Last session, a new faction took a foothold in Montana, spurred by a national coalition of hardline Republicans known as the Freedom Caucus.

- It's a lot of work to do, so.

- [Breanna] This session, the Freedom Caucus made a public showing at the start of the session to outline its priorities.

- It's easy for Republicans to be socially conservative.

I mean, we typically all unite on that.

- [Breanna] While many of these legislators are proud public faces of the Freedom Caucus, other members' identities are concealed and left off the official roster.

But the Freedom Caucus's views are far from secret.

It publishes regular updates during the session on caucus-supported bills and how it recommends members vote on them.

- We are all like-minded, but we're not a hundred percent.

Everybody's not a hundred percent.

- All those in favor- - So far this session, known Freedom Caucus members have uniformly followed the caucus's recommended votes on priority bills.

- [Barry] We are pretty aligned with the Republican Party platform.

- [Politician] House Bill 245 has passed the House.

- We may be a little bit more staunch with it.

- You can't expect everyone to vote the same.

It would be ridiculous.

We represent different people, different areas, different needs.

If we did vote the same, then I would say that's a failure of government.

- [Breanna] Senator Llew Jones, recovering from a detached retina, has seen many versions of factions in his 20 years as a legislator.

The one he meets with is known as the Solutions Caucus, but he says there's no formal membership or prescribed votes.

- We do not recommend that you vote any way.

We recommend that you become well-informed on a topic.

(air whooshes) - [Breanna] The Solutions Caucus and Freedom Caucus represent the party's largest subgroups and include Republicans from both chambers.

But neither group has the number to steamroll legislation, as Ler points out in his 100-seat House.

- The Solutions Caucus doesn't have 51.

The Freedom Caucus doesn't have 51.

The Democrats don't have 51.

So, at the end of the day, you still need 51 votes in this chamber to pass legislation.

- Mr. Speaker.

57 representatives have voted aye.

- [Breanna] that's why majority leaders say it's best to get to know the members of their party as individuals.

- I think it's good and healthy to have a debate within a party as well as between two parties.

I think sometimes people look at that as a bad thing.

I don't think it's a bad thing.

I think we are, we as Republicans benefit from having a variety of different viewpoints.

- [Breanna] Despite their differences, Republicans agree most of the time, and they also agree with Democrats.

- People think, oh, politicians are always fighting and they never can agree and there's, you know, party against party and it's like this, you know?

We agree a lot.

- [Breanna] In fact, in the first four weeks of session, representatives in the House voted in agreement across the aisle 60% of the time.

And when we saw division so far, Republicans in the House split their votes 18% of the time, House Democrats split 12% of the time, and the House has only seen as straight party split on about 9% of the bills.

(air whooshes) At the start of the session in the Senate, a little more than half of the bills drew overall agreement between senators, and straight party splits are happening 1/4 of the time.

But Senate Republicans are four times as likely to split as Democrats, who voted as a block all but two times early in the session.

- Later in the session, you'll see more variety obviously between Democrats and Republicans in terms of how we vote, but also even within our caucus, you'll see a little more variety.

- We will have a couple issues, I think, where you're gonna have divisions in the caucus, and I think Medicaid expansion will be one, for example.

We also have one on what's called Convention of the States.

- Matter of fact, I think I read that a lot of the framers and the founders were saying they liked Article V and the idea of the convention for the states to propose amendments, but they thought this is just too hard.

- Yeah.

- Majority leaders are finding new outlets to share their views.

- [Narrator] Welcome to the "Montana Majority Report."

Quick, transparent, and informative, get the inside- - Even on issues where Republicans are divided.

- When we're relying on the feds, that's a risk.

- Exactly.

- [Breanna] A podcast launched this session welcomes lawmakers who tend to support each other's bills on the floor.

- Perfect, Montana property light, right- - [Breanna] It has yet to feature any of the nine senators who sided with Democrats on that day one rules vote.

- Senator Noland.

- [Breanna] But you don't have to look any further than the floor to see the fracture.

- It's one thing after another that this process is being politicized.

- [Breanna] Following that first day, an ethics issue surfaced about Senator Ellsworth regarding a decision he made at the end of his Senate presidency in December.

- Mr. President.

- Mister- - [Breanna] He awarded a state contract to a former business associate using legislative committee funds and supposedly without using proper protocol.

- It's like, are you kidding me?

It's all public.

- The more this was looked into, the more the concern grew.

- [Breanna] Since then, the Senate has spent much of its time voting on what to do about it.

- This is a distraction.

(electronic beeping) - [Breanna] First, senators, including Ellsworth, agreed to send the investigation to their ethics committee.

- It's not supposed to be a prosecution.

It's supposed to be fact-finding.

- [Breanna] But a week later, the Senate couldn't shake the squabble as Majority Leader Tom McGillvray attempted to remove Ellsworth from the Finance and Claims Committee.

- Have Senator Ellsworth step aside for a few days.

That's, again, that motion is for tomorrow.

- [Breanna] But Minority Leader Flowers move to hand off the investigation to the Department of Justice.

- This issue is getting in the way of our business.

- [Breanna] Setting off senators once again.

- I'm disappointed, I'm embarrassed to be in this chamber at this moment.

- This is about the first day we were here, and we all know it.

This is a political persecution is what it is, but it's also a political charade.

- [Breanna] The debate simmered into another Republican split as that first day faction of nine again sided with Democrats to send the Ellsworth investigation to the Department of Justice- - Has every member voted?

- [Breanna] Leaving a large block of Republicans wondering if they still have the majority.

- You played some shenanigans, you played some games.

Way to go!

You're in power!

- [Breanna] Leaders say every session, emotion can drive the motions.

- People blow off the steam, come back the next day, and you gotta cool down because the next issue's coming right behind it.

- This is nothing.

Sun is gonna come up tomorrow.

Sun's gonna set tonight.

Let's all go home, have a good meal, have a good sleep, come back tomorrow and start over.

- [Breanna] But moving on can be a challenge when policy comes with politics.

For "IMPACT," I'm Breanna McCabe.

- Even if factions of the Republican Party managed to iron out differences or partner with Democrats on a bill, there's one final hurdle they must clear.

Governor Greg Gianforte's veto pen.

That's all for this episode.

On the next "IMPACT," more uncertainty for the federal workforce appears to be on the horizon, but the US Forest Service was already grappling with an unrelated hiring freeze instituted this past fall.

We'll tell you how that freeze is already affecting Montana's outdoor recreation.

And, Montana's seniors are struggling with isolation and loneliness.

We'll explore how local communities and government are supporting them.

(air whooshes) Thanks for joining us.

We'll see you next time.

(pensive music) (pensive music continues) (pensive music continues) - [Announcer] Production of "IMPACT" is made possible with support from the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans, and viewers like you who are friends of Montana PBS.

Thank you.

(air whooshes) (gentle music)