In a report that examines the effects of Medicaid expansion on Montana’s tribal communities, economist Bryce Ward of ABMJ Consulting reports that the program — which must be approved by the 2025 Montana Legislature in order to continue — has been an incredible success in Indian Country, improving the health and even positively impacting life expectancy, while increasing services.
The new report, “Economic Effects of Medicaid Expansion on Montana’s Native Americans and Tribal Communities,” paints a positive picture of how the federal program has been successful for many Native Americans, despite the long-held but inaccurate belief that those same communities had unfettered access to healthcare through the federal government’s Indian Health Services.
Ward points out in the report that IHS health funding is given by Congress in a lump sum, and had previously been rationed, often running out of money before the year’s end. This meant that tribal members would only be covered for “life and limb” emergencies, and all other care was either rationed or simply unavailable to tribal members.
“For so many years, decades, really, the IHS has been dramatically underfunded,” said Dr. Aaron Wernham, the executive director of the Montana Healthcare Foundation, which commissioned the report. Its findings weren’t a surprise, but were more encompassing than the staff had even anticipated.
According to the Daily Montanan, the report shows that since Medicaid expansion in Montana, and Native populations becoming eligible, tribal members have increased in health, and increased access to providers, and meanwhile, Indian Health Services in Montana has been able to cover more services without being overloaded by emergency demands.
Wernham said that Medicaid expansion in Indian Country meant that routine health screening for cancer, diabetes or heart disease would happen more easily, not just when IHS had the time or funding.
“Since expansion, more Montana Native Americans report being in good health, more Native American adults are employed, and the share of households with medical debt in majority Native zip codes fell substantially,” the report said.
But it wasn’t just the individuals that seemed to do better, the report said, it was the economic improvement of the community that was also notable.
“Medicaid expansion also adds millions of dollars to tribal communities,” the report said. “For some tribal communities, the additional resources are equal to several percent of county gross domestic product.”
Furthermore, Medicaid expansion for Native Americans is fully funded without cost to the state, unlike the expansion for non-Native members, which is funded by an approximate 90% federal contribution and a 10% state match.
The report also examines what would happen in Indian Country if the expansion in Montana was not renewed. That could leave as many as 18,000 Montana tribal members without coverage, making them “otherwise uninsured.”
Montana also had the largest percentage of tribal members in the U.S. who said that they quit skipping medical care, such as routine check-ups, after they received healthcare through Medicaid expansion. Forty percent reported they quit skipping healthcare due to costs, which was ahead of New Mexico at 39% and ahead of South Dakota at 16%.
Still, skipping routine healthcare visits due to cost doesn’t mean that those same Native Americans would have not used the healthcare system in Montana.
“Montana’s Native Americans who would be uninsured without expansion still would have used some healthcare,” the report said. “They or other entities would have absorbed the cost of this care. With expansion, these funds are free to support other priorities.”
Since Medicaid’s expansion in Montana, the mortality — or how long a person lives — has improved, especially in areas where Native Americans comprise at least 20% of the population.
The mortality rate of people in those counties improved, on average living 1.4% longer than compared with pre-expansion levels. In contrast, in states where Medicaid had not expanded, life expectancy dropped during the same period.
Larger economic benefits for the community
The expansion has had a trickle-up effect for not only the individual Native American enrollees in Medicaid, but it also has helped drive better economics in the counties and reservations in Montana.
Native American care through Medicaid expansion’s impact is estimated between $125 million and $175 million. And half that amount is spent on IHS or through other tribal health facilities.
“Rising demand prompts more supply,” the report said. “During interviews with tribal health leaders, they stressed that Medicaid expansion allowed them to hire more providers and extend hours of operation, which decreased wait times.”
As they added services, the overall community health improved because it was not just the Medicaid enrollees who benefitted, the report said.
Expansion increased the overall GDP in counties with large Native American populations, including boosting Glacier County’s GDP by 3.8%, Roosevelt County by 3.3%; and Lake County by 3.2%.
What may not have been expected is the sizable impact that would have on some of those county’s workforce.
“The unemployment rate in Montana’s counties with the highest Native American population shares plummeted after expansion,” the report concluded. “Relative to the three years before expansion (2013-2015), on average, unemployment fell by 3.1 percentage points (or 46%) in these counties by 2022-2023. This decline was above the median non-reservation Montana counties in all seven counties.”
The biggest changes were in Big Horn County’s unemployment rate which decreased by nearly 6%.
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