Opinion

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Closing Range

Black Flag 3

Let’s be real: expanded Medicaid users will stay right where they are

I was going to continue trying to explain why medical costs are in an uncontrolled spiral, but now I realize it’s a lost cause. News is, Medicaid expansion will continue until 2025. But is it all fixed under “HELP,” or the Health and Economic Livelihood Partnership act? No, the much-amended, much-held-hostage HB-658 Gov. Bullock is expected to sign is a train wreck, with so many cross-outs and underlines, I doubt anyone fully understands exactly what the law means or what the core problem is with Montana (or American) health care. It sure won’t, as the bill reads, “modify and enhance Montana’s health care delivery system to provide access to high-quality, affordable health care for all Montana citizens.”

In the Flathead, the final vote broke down as I expected. Flathead conservatives all voted no. The Kalispell moderate voted yes. And Columbia Falls’ liberal voted yes.

After much sponsor thunder about “work requirements,” the final version requires 80 hours per month of “community engagement” — toward your total, for example, you can count “substance abuse education or substance use disorder treatment” as “work.” Or, if you have a “job” with income of 80 times minimum wage for the month ($8.50×80=$680), you’re qualified for expanded Medicaid. Recipients will pay a “premium” of 2 percent of adjusted gross income, rising to a maximum of 4 percent after six years.

There’s a “special revenue account” to fund this, with part coming from a 1 percent tax on net premium income collected from “real” insurance providers, plus “taxpayer integrity fees” charged to recipients, starting at $100 per month based on net assets in excess of the homestead exemption.

Hospitals will pay to the state (and bill other patients for) $70 per “inpatient bed day,” as well as pay 0.9 percent of outpatient revenue. Of that, 54 percent will go to the HELP special revenue account.

What was the bottom line of this Rube Goldberg funding arrangement? That’s way down in Section 40 about appropriations: $562 million in federal money (which is NOT a gift from Uncle Sugar to Montana, trust me), $32 million from state general funds, and $33 million in the “special revenue” pool where the above “fees” and “premiums” will be deposited. That’s $627 million, which when divided among the 96,000 expanded Medicaid users, comes to $6,531 per user per year.

Now, remember that “premium?” That’s being charged so that recipients might have some “skin in the game.” Hopefully they will take steps to self-manage their health better, right? Actual insurance charges premiums high enough to pay for the actual care used in the “risk pool,” plus some profit/administrative overhead. For a family of four to qualify for Montana “HELP,” income must be less than $32,900 a year (138 percent of the federal poverty level). Four percent of that is $1,316. Seems kind of short of covering costs, right? Like a subsidy? Oh, gee, that $1,316 is the premium for FOUR people, and EACH user is costing “the government” $26,124 on average, meaning that premium only covers about 5 percent of the real cost of care.

Do the math, kids: If you pay five bucks to get 95, that’s a pretty darn awesome deal, pretty darn, um, “affordable.” To users. No wonder people signed up!

Will beneficiaries ever leave expanded Medicaid, perhaps using the so-called “HELP workforce development grant program?” Why should they? First, to “break even” and make the jump to “private insurance” with a real premium that actually covers your foreseeable costs over time, the simple version is your next job would have to pay (and or benefit) at least $24,000 more per year. Second, what kind of training jumps anyone from $32,000 one year to $56,000 the next? Third, there’s no improvement in net income. And, those falling short of that $56,000, well, they busted the salary cap for HELP. I’m sorry, but expecting grants to work is utter delusion.

Let’s be real. Expanded Medicaid users will stay right where they are. It’s safer to pay $1,316 and let “the government” deal with the other 95 percent of an outrageously unaffordable $26,124 per person, per every single year, forever, cost of health care.