Montana was among the last states to expand Medicaid, and its Obamacare marketplace has fared reasonably well. It has 50,000 customers, decent competition and no "bare counties," where no insurers want to sell plans.
The Republicans who make up two-thirds of Montana's congressional delegation have said they want to repeal the current health care law because it's causing health insurance markets to "collapse."
But insurance executives at the companies that sell policies in Montana's marketplace say that's not true in the state, and they are concerned that GOP plans to repeal and replace the Affordable Care Act would destabilize a market that is working. Jerry Dworak, the CEO of Montana Health Co-Op, said, "I don't think that their plan is going to improve health care in the state of Montana. I think just the opposite is going to happen. And I really do think a lot of people are going to get hurt."
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The co-op is one of the three insurance companies that have been selling Montanans coverage at healthcare.gov since it started in 2013. Dworak said it has no plans to leave.
The executives say a collapse is a real possibility, though, if some of the GOP's wish list comes true. First, deep cuts to Medicaid would have ripple effects to everybody with insurance. Todd Lovshin, a vice president at PacificSource Health Plans, said Medicaid expansion means Montana hospitals are now getting paid for taking care of more than 70,000 Montanans who got Medicaid after the state expanded it under the Affordable Care Act.
"All of our hospitals have to take any patient that comes in and serve them. That has to be paid somewhere," he said. "And if we're not paying that through Medicaid expansion, those costs have to be borne by someone, and so that will increase the overall cost of medical expenses."
Hospitals have a legal obligation to examine and stabilize any patient who walks in their door, regardless of whether they have insurance. When hospitals see their unpaid bills stack up, Lovshin said, prices go up for everybody else and insurers have to charge patients who have insurance more to stay afloat.
John Doran, a vice president with Blue Cross and Blue Shield of Montana, the state's biggest insurer, agreed with that analysis.
Doran also said that problems would likely get worse if the individual mandate goes away. That's the requirement to have health insurance that Republican health care bills do away with.
"If there's no mandate, and there's no incentive for them to buy a health insurance plan, then maybe they won't," he said. "The people who need health care the most, and typically have the highest health care costs, are the only ones who are in the marketplace, and that results in higher health care costs and consequently higher premiums."
Montanans have been seeing insurance premiums go up, sometimes by more than 50 percent a year. Most people who buy on the exchange get subsidies to help defray the cost, and the co-op's Dworak said he thinks prices are now starting to stabilize. If the health law isn't changed, he projects his company's premiums would go up only 5 percent in 2018.