Why Montana Doubled Down on Medicaid Expansion

A broad coalition of bipartisan lawmakers, health care providers, business leaders and consumers just made Medicaid expansion permanent in Montana. Here is why and what it means for the rest of the country.

May 14, 2025

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tl;dr

  • Montana Gov. Greg Gianforte signed HB 245 into law on March 28, reauthorizing the state’s Medicaid expansion and removing a long-standing “sunset provision” on the coverage expansion.

  • Despite the looming threat of proposed federal cuts, the legislative effort succeeded due to bipartisan support, health care provider engagement, business community buy-in and compelling individual stories of how Medicaid is helping Montanans.

  • Data-driven evidence on the impact of Montana Medicaid was critical in building support for expansion among this broad group of policymakers and stakeholders. The data demonstrates, among other things, that Medicaid expansion has strengthened the state’s rural health delivery system, workforce and economy and, most importantly, the health and well-being of Montanans.

  • Members of Congress, now considering a series of “1,000 cuts” targeting Medicaid expansion enrollees that will result in 8.6 million people losing Medicaid coverage would do well to study what happened in Montana and why.

The 80 Million Impact

Montana’s Medicaid program covers more than 200,000 people, including one in three children residing in the state. In the face of potential federal funding cuts to Medicaid generally and expansion specifically, the Montana Legislature in February approved a bill to extend permanently Medicaid expansion, which provides coverage to about 76,000 of those residents. The measure, supported by a bipartisan coalition of legislators, removed the program's sunset provision that had been in place since Montana’s Medicaid expansion was first implemented in 2016. The effort to make expansion a permanent part of Montana’s Medicaid program had bipartisan support, buy-in from the business community and hospital association, and was bolstered by compelling human stories and data that provided evidence on the value of Medicaid expansion, including work done by the Montana Healthcare Foundation.

Montana’s Medicaid expansion story may be surprising to some: Montana is a red state with a conservative governor and legislature that came to expansion later than many states, but after nearly 10 years’ experience has chosen to make expansion a permanent part of providing affordable health coverage to Montanans. The Montana Medicaid story is an encapsulation of how perceptions and politics around Medicaid have evolved over a decade because of the program’s powerful, positive impact on working low-income people, health care providers, businesses and the economy. Montana’s story aligns with the strong voter support for Medicaid across the nation, including among Trump voters, and should be a wake-up call for members of Congress as they contemplate a series of legislative changes that would significantly reduce Medicaid funding, especially for expansion states, and terminate coverage for 8.6 million people enrolled in Medicaid.1

Sen. Josh Hawley, the Republican senator from Missouri – also a red, expansion state, is among those sounding the alarm for his colleagues in Congress saying in his May 12 New York Times op-ed: “If Congress cuts funding for Medicaid benefits, Missouri workers and their children will lose their health care. And hospitals will close. It’s that simple. And that pattern will be replicated in states across the country.”

Montana similarly concluded that Medicaid expansion works, including for working people. Here are the factors that led the state to double down on expansion:

Medicaid strengthens and sustains rural health care providers

Montana’s Medicaid program, including expansion, has played a critical role in strengthening the state’s rural healthcare system. Ninety-three percent of Montana’s critical access hospitals have added or expanded specialty care services since 2016 when Montana expanded Medicaid, per the Montana Healthcare Foundation. In the same timeframe, 87% of those hospitals increased their behavioral health services, including substance use and mental health treatment programs — a notable addition in a state with the highest suicide rate in the nation. Importantly, when a rural hospital adds a new service, it becomes available to the whole community, not just Medicaid enrollees. In a rural state like Montana, the next closest provider could be hundreds of miles away, so having services close to home really matters to people.

Expanded coverage through Medicaid expansion provides vital funding for rural hospitals. Since passage of the Affordable Care Act (ACA), the majority (74%) of rural hospitals closures occurred in states where Medicaid expansion was not in place or had been in place for less than a year, and no rural hospitals in Montana have closed since Montana expanded Medicaid.

The Montana Hospital Association (MHA) made the case for Montana’s Medicaid program to the legislature on behalf of its members this year, spearheading a strong public messaging and communications campaign showcasing the benefits of expansion. MHA partnered with Montana’s broad and well-organized health care coalition, Montana’s National Alliance on Mental Illness and the Montana Chamber of Commerce in the push.

Medicaid expansion enrollees are key to the workforce and economy

Despite the national rhetoric about Medicaid expansion enrollees not working, national and local data show a very different picture. In 2023, most of Montana Medicaid expansion enrollees held payroll jobs — representing one in six of the state’s private sector employees, according to a January report from the Montana Department of Labor and Industry. Of those workers, 68% were employed for every quarter they were enrolled in Medicaid expansion and 91% were employed for at least half of the time they were enrolled.

Montana business leaders attested to the importance of expansion, showing up as strong supporters of continuing it. Todd O’Hair, president and CEO of the Montana Chamber of Commerce, told The 80 Million that Medicaid expansion was its #1 priority in the 2025 legislative session.

“The rationale was simple: access to health care is foundational infrastructure for economic development,” he said, noting that Montana has seen population growth in its urban areas but not in rural ones. “Montana’s rural communities are eager to recruit new business investment in their area. Medicaid expansion is vital to not only maintaining their presence, but also in their efforts to recruit new and expanding business into their community.”

“We know that over 20,000 Montana businesses employ workers who participate in the HELP Act (Medicaid expansion),” Montana Rep. Ed Buttrey, the Republican who sponsored HB 245, said in a Feb. 7 House floor session. “This includes 72% of food and accommodation, 52% of retail, 45% of manufacturing, 37% of agriculture and 33% of construction businesses. These businesses are the backbone of every Montana community, and they rely on our program to provide them with a healthy, trained, and reliable workforce.”

Notably, Montana’s expansion legislation maintains a work requirement from the original authorizing legislation, the HELP ACT, and the new bill requires the state to contact Medicaid enrollees who meet the criteria for work requirement to have them complete an optional work assessment. The proposed House budget reconciliation legislation would not allow Montana to continue with its current approach which is tailored to the needs of its expansion population — taking into account the evidence that Montana expansion has helped working people access the health coverage and care necessary to become and stay employed and the imperative to prevent an administrative reporting requirement from disrupting coverage for eligible people.

Medicaid ensures affordable health coverage and health care

Many Montanans spoke at legislative hearings about what Medicaid benefits mean to them, both from an individual and business standpoint. In a Feb. 7 legislative session, Montana Rep. Donavon Hawk shared that he qualified for Medicaid after filing for bankruptcy — a lifeline that allowed him to get back on his feet. Like millions of other Americans who receive Medicaid benefits, he’s worked his whole life but until Medicaid expansion, he had no health coverage.

“If it wasn’t for Medicaid expansion, I wouldn’t have been able to get financially secure. I wouldn't have been able to get my finances in order,” Hawk said. “Had I not been able to do that, I would not have been in a place to adopt and start taking care of my niece and nephew. I’m proud I can do that, that I’m able to have the capacity to take care of two human beings — and it was all because of Medicaid expansion."

The data also paints a clear picture: Medicaid is a stabilizing force for Montanans. During this year’s expansion debate — and the several preceding it — both advocates and legislators regularly used and quoted from Montana Healthcare Foundation’s reports that provide year-over-year data on the impacts of Medicaid generally (and expansion specifically).

The Bottom Line

Medicaid, including Medicaid expansion, provides affordable health care coverage not just for Montanans, but for millions of Americans, enabling them to access the health care they need to work, take care of their families and thrive. The success of Montana's legislative effort to make Medicaid expansion permanent, supported by bipartisan lawmakers with the strong backing of a diverse set of stakeholders, demonstrates the impact the program has in strengthening rural health systems, supporting the workforce, and boosting the economy.

Montana shows us that the rhetoric about expansion heard in our nation's capital, and the efforts to terminate coverage and access for millions of people enrolled in expansion using “1,000 cuts” proposals in budget reconciliation legislation, is far afield from the experiences of people, businesses, health providers and state policymakers across the country.

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