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This is really a debate in 2019: Conservative legislators in Montana are demanding that the coal industry get state support or else they will not support a renewal of Medicaid expansion. And the deadline for a resolution of the nonsensical linking of the two issues is Monday.

The outcome of this debate is significant to the Indian health system. One recent study found that at least 15,495 eligible American Indians have been insured through Medicaid expansion. “Not only does this have the potential to help close the staggering American Indian health disparities gap, it brings much needed health care dollars” into the Indian health system, according to the Montana Budget and Policy Center. And, as the center points out, Additionally, any service provided through the Indian Health system and its providers “qualify for 100 percent federal reimbursement and therefore are provided at no cost to the state Medicaid program.”

Medicaid is a partisan debate that is being played out across the country. Republicans are eager to roll back Medicaid while Democrats are eager to expand the public health insurance program.

Medicaid is a state-federal partnership. So the states set the rules. But the Indian health system is stuck in the middle. The federal government pays the bills for eligible American Indian patients under a 100 percent federal match. So when states walk away from Medicaid, it costs the Indian health system funding. Officially the Indian Health Service receives $1.19 billion from third party billing, mostly Medicaid. But the number for the entire system is much larger because tribal, urban and nonprofit providers are not included in the IHS budget.

The Medicaid debate in Montana was complicated when voters rejected a measure to codify the expansion and pay for the insurance programs with tobacco taxes. The vote was 52 percent against. Last month the state House reached a compromise on Medicaid, reauthorizing the program, but adding the work rules that Republicans demanded. But the Senate could not reach a deal. The measure failed by a single vote, a tie of 25 for and 25 against.

As the Helen Independent Record reports there is now a trade-off demand: If you want public health insurance, save the state's coal industry. The headline: "Montana's Medicaid expansion hangs on Colstrip deal."

Sen. Tom Richmond, a Republican from Billings, had signed onto the Medicaid expansion bill but is voting no. He told the Helena Independent Record: “We have some issues with one of my bills and we'll see what that’s going to be a little later on.” The issues, the Record says, was "one of his bills is to let NorthWestern Energy, the state's monopoly utility company, buy 150 megawatts of interest in the Colstrip Power Plant while prohibiting the state's Public Service Commission from oversight of the $75 million in increased costs the move would mean for ratepayers.”

Tribal leaders have spoken out in favor of reauthorizing the legislation. “Medicaid expansion is critical for improving American Indian health and health care delivery systems in Indian country,” President Andrew Werk Jr. of the Fort Belknap Assiniboine, Nakoda, and Gros Ventre, Aaniiih, Tribes said in the State of Tribal Nations in February.

Montana Gov. Steve Bullock tweeted that governing is not a game. He said in a statement that the nearly one hundred thousand people who rely on the Medicaid expansion cannot trade votes. “The only choice they have is whether they get the health care they need or whether they can put food on the table for their families.”

Senators again debated Medicaid on Saturday, but could not reach a deal.

Sen. Jason Small, a Republican, is sponsor of the Medicaid legislation. (Photo: Facebook)

Sen. Jason Small, a Republican, is sponsor of the Medicaid legislation. (Photo: Facebook)

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Sen. Jason Small, Northern Cheyenne, is a Republican, and the sponsor of the Medicaid legislation. He said in a video interview on Facebook with Western Native Voice that the impact of Medicaid is “incredible.”

He said Montana could lose out on about $300 million a year in personal income. “We'll be losing the rural hospitals, rural clinics. They're going to be losing out. It's going to be very difficult to keep them funded and going,” he said. And the Indian Health Service for the “first time in a hundred years it's been working, right? So we're going to lose that too, that we'll be back down to life or limb at some point.”

“It's pretty much all of Montana,” he said,.There are 18,000 businesses and 57 percent of those actually have an employee on Medicaid expansion. “So it's a pretty unbelievable number. (Small also supports the coal legislation, but does not tie the two together as an either, or.)

“It is heartbreaking to know that some of our legislators are putting special interest and partisan politics before the lives of 1 in 10 Montanans,” said Marci McLean-Pollock, executive director of Western Native Voice said in a news release. “It is shameful that these senators are reinforcing the belief that the lives of working Montanans can be used as political pawns and that they are putting corporate profits before the lives of their constituents.”

“As if fleecing captive ratepayers wasn't bad enough, now these guys want to hold Montana's most vulnerable families captive to their corporate welfare scheme,” said Beth Kaeding, a member of Northern Plains Resource Council who testified in opposition to SB 331 earlier this week. “This small band of legislators is holding healthcare hostage for 90,000 Montanans unless their demands are met to funnel 75 million dollars to NorthWestern Energy, an out-of-state monopoly utility. It's a naked display of corruption reminiscent of the days when the Copper Kings ruled the state.”

The Montana Senate has a deadline. Monday is the last day that legislation can be enacted without requiring a supermajority from at least one house. 

Montana has more American Indians serving in its state legislature, including three in the Senate, two Democrats and one Republican. All three support the Medicaid expansion legislation.

Medicaid expansion is scheduled to expire June 30 in Montana unless the legislature re-authorizes it.

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Mark Trahant is editor of Indian Country Today. He is a member of the Shoshone-Bannock Tribes. Follow him on Twitter - @TrahantReports

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