Montana's Medicaid Expansion Is Getting Weird

Something about Medicaid recipients being a lot like radishes. Wut?

In 2015, Montana legislators finally voted to accept the dirty federal money that came with Medicaid expansion. The program expanded in 2016 and has been a big success, with 95,000 people now getting healthcare who had previously gone without. However, because Montana Republicans are assholes for Jesus, there's a built-in time limit: The Medicaid expansion will expire June 30 unless the Lege votes to renew the program. That's inspired Montana Republicans to "improve" the state's Medicaid program by insisting any re-up of Medicaid add "work requirements," which are all the rage in wingnut-run states these days. To make sure people aren't slacking, poor Montanans would also have to pay higher premiums to even use Medicaid.

Oh, yes, and a George Washington University study released Wednesday estimated the combination of higher premiums and work requirements would kick between 31,000 and 43,000 low-income Montanans off Medicaid. That's one hell of a reform, eliminating a third to nearly half of the number who gained coverage just three years ago. But you see, Republicans are very worried that the poor may just stubbornly insist on not getting rich fast enough, so yanking healthcare away from tens of thousands of people will surely force them all to go get rich, which they would otherwise not care to do.

The study identifies some of those who'd be most likely to lose access to healthcare under the Republican plan:

Sounds like a bunch of lazy takers,all right! The report also notes that work requirements seem like a strange thing to demand of Medicaid recipients, given that when the state expanded Medicaid, it also instituted "HELP-Link," a voluntary program that "connects Medicaid enrollees with high quality workforce training, employment services, and job openings in local communities," as the program's homepage puts it. The program touts some pretty impressive stats, too:

So if people on Medicaid are already volunteering to get trained and improve their job prospects, why impose work requirements that will throw tens of thousands off their insurance? EASY! Because Republicans are absolutely certain that anyone on Medicaid is REALLY just sitting around watching TV and sinning while stuffing themselves with gold-covered bonbons bought on the taxpayer's dime, that's why.

In fact, one intrepid Republican in the Montana House, state Rep. Frederick "Eric" Moore, has introduced a bill, HB 433, that would drill down in great detail into all Medicaid and CHIP recipients' financial and health records to find out just who's getting services through Medicaid, and whether they're actually the Worthy Poor or Welfare Queens. For starters, the state Department of Revenue would have to give the legislature's "fiscal analyst" an anonymized version of every single individual tax return (with the option of adding the names back in if the Lege really needs the info). The bill also would require Montana's Department of Public Health and Human Services (DPHHS) to report all of the following to the fiscal analyst, after first scrubbing the records of "names, addresses, and social security numbers" and substituting a number to identify the record. Really, it's all very simple! All Moore wants is everything, after all:

And he only wants everything every month! 

And then after the data has been delivered to the legislature, the anonymized medical records of everyone on Medicaid and CHIP (plus "all public assistance and health care enrollment information") would "be filed in the respective offices and be made available to the legislature and the public." You could maybe even look online to see if any poors got treatments you don't think they're entitled to.

Not surprisingly, at a hearing Wednesday on HB 433, DPHHS Operations Services Branch Manager Erica Johnston testified the bill could "compromise the identity and health privacy of literally hundreds of thousands of Montanans," including "all current Montana Medicaid, SNAP, TANFF, and child welfare participants." She added that CHIP and Medicaid alone cover "the lives of nearly 300,000 Montanans [...] almost 1/3 of our population."

Johnston also said the law might very well violate HIPAA, the federal medical privacy law, yes, even if patients' names and Social Security numbers were removed (HIPAA's "de-identification" guidelines require far more extensive data scrubbing). She said DPHHS is still doing a legal review on the question, but pointed out her department handles some incredibly sensitive information, like child abuse cases and addiction recovery programs. The data HB 433 includes under "all" could easily be mined to identify people quite accurately. Beyond that, the cost of compiling and delivering all that data -- monthly -- would be unreal.

Moore argued for the bill's fairly astonishing invasion of medical privacy by insisting that Republicans simply don't have enough information on whether Medicaid really works at all. Mind you, DPHHS issued a 64-page report in January on the state's Medicaid program, with a wealth of information on the populations served and the services provided, but no, that's just not good enough, said Moore , because poor people are a lot like radishes, or maybe garbage bags. In a closing ramble, Moore likened the shocking lack of detailed data to trying to run a grocery store chain when one store refuses to tell the company board anything more than overall sales figures.

At most of the stores, he explains, you can see the details, like "Pampers selling more than garbage bags, and we sell cherry tomatoes better than we do celery." But the one store he says is just like the state's Medicaid program will only tell the board of directors it sold ten million dollars in groceries but nothing more. The board isn't allowed to see the raw figures. That one store is just making it impossible for the board to make good decisions!

Oh, sure, he said, the uncooperative store might offer an opinion and say it believes celery is selling better than radishes, but if the board asks for the detailed sales data, the manager says, "We have it, but it would violate a radish law. We can't tell you." HIPAA is that radish law, you see. Moore immediately insisted he wasn't making light of HIPAA, and insisted his bill isn't about the politics of Medicaid expansion (which he vehemently opposed in 2015 , because whenever "social welfare programs" are instituted you just can't get rid of them).

No, no, not political, he insisted. Rather, being able to rummage through poor people's medical records (and more!) is simply doing due diligence before reauthorizing the program. About adding a work requirement that will leave tens of thousands with no healthcare because they're not worthy, Moore said, legislators need data to answer one basic question:

Is the Medicaid expansion population truly a step up to economic self-sufficiency, or have we created another entitlement class? And nobody knows the answer to that question with any degree of statistical certainty. We all have our opinions, which is I guess what we'll have to make our vote on an opinion instead of facts, because we don't have the data.

That is some pretty impressive demanding of facts there, since as anyone knows, the terms "a step up to economic self-sufficiency" and "another entitlement class" are completely objective, factual categories that can be found by looking closely at the medical claims of people you suspect are lazy and undeserving. For all his radishes, celery, and Pampers, Moore didn't quite explain how digging through a lot of Medicaid and CHIP data would clarify that question.

A cynic might even suggest there's little purpose to demanding all those details outside the chance that some poor people might be deemed unworthy. Look at all the smokers! Why are we treating welfare recipients' obesity? They shouldn't let themselves be fat! We are, of course, only speculating. Or as some radical pro-Medicaid crazies put it:

This isn't about work. It's death by 1000 paper cuts. The GOP has a new way to crush the poor with bureaucracy: … https://t.co/IUQjtcYbRf

— Healthy Montana Future (@Healthy Montana Future) 1550126360.0 

Yr Doktor Zoom is not a medical doctor, but we're fairly sure there's no place on hospital admissions forms, prescription receipts, or well-baby checkups where patients are asked, "do you agree not to be a burden on the taxpayers?" Eh, it's Montana -- maybe Republicans can demand that question be added for all interactions between poors and medical staff.

But if Rep. Moore really wants to read some detailed analysis, he could start with all the public information on the DPHHS website. Or that paper on how many people will lose coverage due to an arbitrary work requirement. Obviously, a survey of Medicaid expansion recipients released earlier this month (70 percent say it's improved their access to care) is worthless, since it only shows the takers like taking.

[ HB 433 text / 2019 Medicaid report to Montana Legislature / Montana House Appropriations Committee hearing / Montana Public Radio / Montana HELP-Link / Clyp.it / Milken Institute of Public Health report / Bozeman Daily Chronicle / The Missoulian / Hat Tip to Erin Kelly on Twitter!]

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