Gov. Steve Bullock and House District 17 Rep. Christy Clark toured Teton Medical Center in Choteau last week and pledged to tackle the issue of some 70,000 working Montanans who have been left in a “coverage gap” by the federal Affordable Care Act.

Bullock, a Democrat, has already rolled out his plan to provide coverage to Montanans who make too much to qualify for existing Medicaid coverage, but who don’t make enough to qualify for tax credits to off-set policy costs on the federal insurance exchange.

Bullock’s Healthy Montana Plan would accept federal Medicaid expansion dollars available through the Affordable Care Act, but is patterned after the successful Children’s Health Insurance Plan (CHIP) program in that it uses a third-party administrator from the private insurance field.

According to the Governor’s Office, any Montanan making 138 percent or less of the federal poverty level would qualify to receive health are coverage under the Healthy Montana Plan. Federal funding would be available to pay 100 percent of the cost of the plan for the first three years. Thereafter the state would have to pick up 10 percent of the total costs.

The Governor’s Office says that putting this plan into effect would reduce the need for state funding for several existing programs that provide services to uninsured people with mental health and substance abuse needs. The plan would also reduce the burden of uncompensated care that is increasing the price of health insurance for the currently insured, and straining the budgets of Montana critical access care facilities, Bullock says.

Bullock’s HMP is contained in House Bill 249, which will go first to the House Health and Human Services Committee. It is one of at least three plans to address the coverage gap that are likely to be debated in the House. Another plan will come from the Republican party while a third plan will be introduced by a moderate Republican, Sen. Ed Buttrey of Great Falls.

Bullock and Clark said they were both in Choteau on Feb. 5 because Teton Medical Center epitomizes the plight of Montana’s 48 rural Critical Access Hospitals, most of which are struggling to make ends meet as they face higher costs of doing business to comply with new federal regulations, have a great disadvantage in trying to recruit new family or general practice, physicians, and are literally giving away millions of dollars in “charity” care and “bad debt” write-offs to people who don’t have any insurance.

Teton Medical Center is a 10-bed Critical Access Hospital with a 36-bed licensed long-term care facility and a co-located community clinic, whose professional staff covers the TMC emergency room every day, all year. Last year, TMC wrote off $214,000 in bad debt and charity care, and that’s not a surprise since 42 percent of people who use TMC do not have health insurance.

TMC Administrator Louie King, who gave Bullock and Clark a tour of the facility, said, “One of major problems we face is caring for people without health insurance,” adding that these people are lower-income, hard-working community members who need access to affordable healthcare.

King said Medicaid expansion studies done in Oregon and Washington show that if Montana implemented Medicaid expansion, TMC would see that 42 percent figure drop. “The Healthy Montana Plan is crucial to Critical Access Hospitals like Teton Medical Center. Please support the governor in this needed program,” King said during the listening session held in the conference room at TMC.

Not only would that help TMC’s bottom line, he said, but from a medical standpoint, the expansion would help local people access preventative healthcare in a timely manner and lead to a healthier community.

“Dr. Judy Borland, our medical director, was not able to be at this meeting today,” he said, “but she can tell you stories of patients that delay lab tests, medical treatment and ultrasound studies because they say they can’t afford it. Many local patients will delay treatment of chronic illness because of financial issues and end up in the ER, the most expensive option for treatment.”

King also noted that TMC is one of the county’s largest single employers with 75 full- and part-time workers. A recent economic impact study of the hospital shows that it contributes around $15 million a year to the local economy, King said, and it provides services that are vital to Skyline Lodge, a private retirement complex; Bee Hive Home assisted living center; the county-owned Teton Nursing Home; and Choteau Activities Inc., which provides services to developmentally disabled adults and employs another 40 people in town.

“It would be an economic disaster for this community to lose this hospital,” he said.

And, even with Medicaid expansion, the change is likely coming too late to save TMC, a government-operated, independent facility, run by the five-member elected board of the Teton County Hospital District that had an operating loss of $342,000 last fiscal year.

With rapidly changing federal regulations and ongoing changes in technology and demographics, TMC and other small stand-alone hospitals are likely going to join the emerging national trend of affiliating with much-larger tertiary care centers, King said. The hospital board is currently in negotiations with Benefis Health System of Great Falls to sell the facility to the much bigger provider.

Bullock called TMC an “incredible, incredible facility” and said the state has a duty to respond to the crisis in rural healthcare and the Healthy Montana Plan will be a good start.

“The Healthy Montana Plan we have proposed would accept federal dollars that right now are going to other states, and through partnering with the private sector, provide the opportunity for coverage for 70,000 more Montanans,” Bullock said.

Bullock also said his HMP would have controls imposed to reduce fraud and abuse and those managing the plan would have to report back to the Legislature and him on its effectiveness.

His plan would also encourage people to obtain medical care when their health issues are small and manageable, not when they have become major concerns. Medical bills remain the No. 1 cause of personal bankruptcy filings, Bullock said.

Bullock also said that some form of Medicaid expansion is receiving support from the Montana Chamber of Commerce, veterans groups, human resources advocates and medical providers. “We have put together a great proposal,” he said of the HMP.

But Bullock also told the community members who attended his listening session that he is willing to work with legislators to adopt a proposal that may not be HMP exactly, but still meets the same goals.

“We need to get this done for all of Montana from my perspective,” he said.

County Commission Chairman Joe Dellwo, a rancher from Bynum, told Bullock that the state has to do something to help rural hospitals survive. Rural hospitals are critical to the local economy and they save lives. “You can hear those stories up and down main street,” he said.

Former emergency medical technician Jack Conatser, now the mayor of Choteau, said he used to worry about getting his patient to TMC. Now, however, he’s worrying about the health of all the citizens in Choteau.

“I’m seeing things from a different side now,” he said. “But your program will help keep this place open and in turn keep our community healthy.”

Clark, a Republican rancher and small business owner, who represents Teton County in the Legislature, said she and Bullock are committed to finding a solution and she wants to hear from local constituents on what option — of several to be presented — she should endorse.

“Our failure from the last session was that we did not find a solution,” she said. “I’m not willing to come home this time and say we couldn’t come up with something.”

Jim Hodgskiss, a county commissioner, said some of the discord among the Republican party is over whether Medicaid expansion would be sustainable “after the federal money runs out.”

Bullock said that the federal government would pay 100 percent of the program costs through 2020 and after that the state would need to pick up 10 percent of the costs. If the federal government reduces its support, then the state would have to scale the program back, Bullock said.

Bullock and Clark both said Medicaid expansion faces a big opponent in the Kansas-based Americans for Prosperity group, founded by the conservative Koch brothers, which is actively campaigning through postcards, telephone calls and “town hall meetings” to pressure Montana legislators to forego Medicaid expansion.

But, Bullock said, Montanans need to set their own priorities and stand up to out-of-state interests that may have no idea what it’s like to live and do business in Montana.

“The fabric of our rural lives and communities is dependent upon the opportunity to know that if something goes wrong, you won’t have to travel 60 miles to just see a doc or go to the ER,” Bullock said.

Clark said Montanans have already paid into the fund that Washington, D.C., is offering for Medicaid expansion and it doesn’t make sense not to get some of this money back. “It’s our money,” she said.

“As a Republican I don’t like increasing federal programs, but I don’t like the reality of living in a community that does not have a hospital,” she said, adding that families with children and retirees will be discouraged from locating to towns without adequate healthcare facilities. “We are different than Billings,” she said.

Clark also held out a hope the Legislature will be able to reach a compromise. “Somewhere in there is middle ground. Republicans and Democrats alike, at least the group of Republicans that I travel with, have committed to finding a solution,” she said.