142,000 montanans face uncertainty of health coverage with threat of affordable … · 2018. 3....

142,000MontanansFaceUncertaintyofHealthCoverageWithThreatofAffordableHealthCareActRepeal

Winter2017

ThroughaccesstohealthcoverageundertheAffordableCareAct(ACA),Montana’suninsuredratehasdroppedfrom20%in2012to7.4%in2016,withthousandsofMontanansaccessinghealthcoveragethroughthehealthmarketplace.1CongressandPresident-electTrump,however,havestatedtheirintenttorepealtheACAinearly2017,withoutsimultaneouslyputtinginplaceanyreplacement.2ThiseffortcouldhavedisastrousimpactsonMontana,leadingto142,000fewerMontananswithhealthcoveragethanifhealthreformwereleftinplace.Atthegreatestriskaretheover61,000MontananswhogainedaccesstoaffordablehealthcarecoveragethroughMontana’sMedicaidexpansionplan.Inthepastsixyears,12.8millionAmericanshavegainedaccesstohealthcarecoverage.3RepealingtheACAwithoutincludingaclearreplacementthatensurescontinuedaccesstocareposesasignificantthreattotheeconomy,andcreatesuncertaintyformillionsofAmericans.

MontanansDeserveAnswersAboutFutureHealthCareCoverage

WhileCongressandPresident-electDonaldTrumphavepreviouslystatedtheirintentto“repealandreplace”theACA,itappearsthatCongressintendstomoveforwardwithrepealofACAthatwillnotincludeaplanforreplacement.

Americanshavearighttobeconcernedabouttheseriousnessofplanstoputinplaceanyreplacement.SincetheenactmentoftheACAin2010,Congresshastakenover60votestorepealACA,butithasnevervotedonanyreplacementproposal.RepealingtheACAwithoutareplacementplanendangersthehealthandlivelihoodofthousandsofMontanans.

WhilethisreportfocusesprimarilyontheimpactofACArepealonthosewhohavegainedaccesstocoveragethroughMedicaidexpansion–thosewhoaremostatriskoflosinghealthcoverage–weacknowledgethatrepealofACAalsothreatenstheexistinghealthinsurancemarketplacethathasprovidedover52,000Montanansaccesstohealthinsuranceatmoreaffordablerates,greaterconsumerprotectionsforthoseobtaininginsurancethroughemployers,andimprovedcoverageforseniorsforvitalprescriptionsdrugsthroughMedicare.TheseMontanansalsofacegreatuncertaintiesinthefutureoftheirhealthcare,withoutaclearreplacementforACAarticulated.BecauseCongress’currentproposalwillrepealACAwithoutreplacement,thisreportdoesnottakeintoaccounttheimpactofayet-to-bedevelopedreplacement.

P a g e |2www.MontanaBudget.org

MontanaFamiliesFaceUncertaintyandDisastrousConsequencesofACARepealPriortotheACA,astaggeringoneinfiveMontanansdidnothavehealthinsurance,withtheoveralluninsuredratehoveringaround20percentofthetotaladultpopulation.Today,thatuninsuredratehasdroppedbymorethanhalf,tojust7.4percent,nearlyathirdofwhatitwasbeforetheACA(seeChart1).4ShouldCongressrepealtheACA,studiesshowthatapproximately142,000Montananswouldlosehealthinsurance.5Nationalstudiesshowthatthislossincoveragewouldoccurprimarilyforfamilieswithatleastoneworkerandamongindividualswithoutcollegedegrees.WithoutanyoftheACA’sprovisions,thenumberofuninsuredMontananscouldjumpto227,000.6Ofthese142,000Montananslosingcoverage,23,000haveaccessedsubsidiesandtaxcreditstomakehealthinsurancemoreaffordable.7In2016,thosethatpurchasedhealthinsurancethroughthefederalhealthmarketplacereceivedanaverageof$306inadvancepremiumtaxcredits,covering73%ofthecostofmonthlypremiumsforinsurance.8WiththerepealoftheACA,theseindividualsfacetheriskanduncertaintyofnofuturefinancialsupporttohelpdefraythecostofinsurance.RepealcouldcauseagreaternumberofuninsuredMontanansthanbeforetheACAwasenacted(SeeChart2).InadditiontocoveragelosstothosewhohavegainedinsurancethroughMedicaidexpansion,premiumtaxcredits,andcost-sharingassistance,manyothersfacelossofinsuranceasaresultofdisruptionsinthenon-groupinsurancemarket.9

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WithRepealofACA,MontanaWouldHavetheHighestRatesofUninsuredChildrenandParentsintheNationACArepealcouldhavesignificantnegativeimpactoncoverageofchildren.Currently,onlysixpercentofMontana’schildrenareuninsured,butACArepealandproposedchangestotheChildren’sHealthInsuranceProgram(CHIP)coulddrasticallychangethat.In2009,thestatevotedtoexpandeligibilityforCHIPtoprovidecoverageformorelow-incomechildren.10Today,over120,000MontanachildrenreceivecoveragethroughHealthyMontanaKids(HMK),withapproximatelythree-fourthsofthosereceivingcoveragethroughMedicaid.11Underfederallaw,statesarerequiredtomaintainthecurrentlevelsofeligibilityforCHIPchildrenthrough2019(calledmaintenanceofeffort,orMOE),inordertoreceivefederalMedicaidpayments.12However,ACArepealproposalshavealsomoveduptheexpirationofthisprovisionto2017,puttingatriskwhetherstateswillmaintaincurrenteligibilitylevels.Furthermore,federalfundingforCHIPexpiresonSeptember30,2017.ShouldCongressnotrenewCHIPfunding,statesmayalsofacebudgetarypressurestoeliminateseparateCHIPprograms.13Ineachofthesescenarios,MontanacouldfacesignificantbudgetarypressurestoreducethenumberofchildreneligibleforCHIP.AccordingtoUrbanInstitute’sstudy,arepealofACAincombinationwithreductionsinthestateCHIPeligibilitycouldresultin41,000Montanakidslosinghealthinsurance,causingtheuninsuredrateforchildrentoriseto22.8%.14MontanaparentswouldalsobeatriskunderrepealofACA.Forty-twothousandparentscouldlosetheirhealthinsurance,withnearlyoneinthreeMontanamothersandfathersgoingwithoutinsurance.Thistoowouldrepresentthehighestuninsuredrateamongparentsinthenation.Studieshaveshownthatchildren’swellbeingisimpactedbytheirparents’accesstohealthcare,andtheconsequencesofcuttingparents’insurancecouldbefarreaching.15AmericanIndiansWouldSeeDisproportionateEffectsofRepealACArepealcouldalsohavesignificantimpactonAmericansIndians’accesstohealthservices.RepealingMedicaidexpansioncouldjeopardizetheimprovementsMontanahasmadeimprovinghealthcareaccesstoIndianCountry,andputunduestrainonhealthcarefacilities.Over8,000AmericanIndiansenrolledinMontana’sMedicaidexpansionplanandwouldbeindangeroflosingtheirhealthcarecoverageunderrepeal.16Additionally,Congress’intentionstorepealACAcouldputatrisktheprovisionswithintheIndianHealthCareImprovementAct(IHCIA),includedintheACAin2010.UnderIHCIA,federalandthird-partyprovidersareabletonowreimburseIndianHealthService(IHS)forservices,giving

IfCongressrepealsACAandmakesfurthercutstofederalCHIPfunding,Montanacouldfaceanuninsuredrateof22.8%forchildrenand31%forparents.

Theserateswouldbethehighestinthenation.

Source:TheUrbanInstitute,December2016

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IHSandtribalservicesmuch-neededrevenueandtheabilitytoexpandservices.17Nationwide,reimbursementsatIHSfacilities,tribaloperatedfacilities,andurbanIndianclinicshaveincreased21%sincetheexpansionofMedicaid.18In2014,nearly40%ofAmericanIndiansdidnothavehealthinsurance,butMedicaidexpansionrepresentedoneofthemostsignificantopportunitiestoexpandcoverageforAmericanIndians.19,20Over61,000Low-IncomeMontanansFaceLosingHealthCoverageThe61,000MontananswhogainedhealthcarethroughMedicaidexpansionareinthegreatestdangeroflosingtheirhealthcareiftheACAisrepealed.By2019,theyearrepealisslatedtotakeplace,over74,000thousandMontananscouldbenewlyenrolledandindangeroflosingtheirhealthinsurance.21MontanaExpandedMedicaidwithBipartisanSupportDismantlingMedicaidexpansionoverturnsthedesireoftheStateofMontanatoprovideaccesstohealthcareforthosemostinneed.In2015,withbipartisansupport,theMontanalegislaturepassedtheHealthandEconomicLivelihoodPartnership(HELP)Act.22Thisplanallowedthestatetousethefederalfundingavailableforexpansiontoprovidehealthcarecoveragetoadultswithincomesoflessthan138%ofthefederalpovertyline(incomeof$16,384ayearforanindividual,$27,821forafamilyofthree).23MontanaimplementedMedicaidexpansionusingathird-partyinsurancecompanytoadministertheprogram.Montanawasthefirststateinthecountrytodesignandimplementthisuniquesolution,usingasimilarmodelasthesuccessfulHealthyMontanaKidsprogram.

HealthandEconomicLivelihoodPartnershipProgramTheHELPPlandiffersfromtraditionalMedicaidexpansioninafewways,themostsignificantofwhichisthatathird-partyinsurancecompanyadministerstheprogram.Participantsintheprogramreceivehealthinsuranceservicesthroughthethird-partyinsurancecompanythatcoversthesamerequiredservicesasMedicaiddoes.Montana’splanalsorequiresHELPActparticipantstopaypremiumsofuptotwopercentoftheirincome.

WhoMightLoseHealthCareCoverage?Ofthe61,233HELPplanmembersindangeroflosingtheirhealthcarecoverage:

• 34,000arewomen• 52,000arelivingbelowthepovertylevel• 41,000arepeoplelivingat50%orlessofthe

federalpovertylevel• 8,000areAmericanIndian• 14,000arebetween50-64yearsold

KeyFactsabouttheHELPPlan

• ProvidescriticallyneededhealthcaretolowincomeMontanans

• Firstplanofitssortinthecountry• Healthcarecoveragethroughathirdpartyadministrator

• Requirespremiumsandco-payments

• Connectsparticipantswithjobsandtrainingprograms

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Participantsalsopayco-payments,butpremiumsandco-paymentscombinedcannotexceedfivepercentoftheirincome.Peoplelivingabovethepovertylinemayberemovedfromtheprogram.24TheActalsocreatedtheHELP-Linkprogram,avoluntaryjobservicesprogramthathelpsconnectprogramparticipantswithworkforcetraining,employmentservicesandjobopenings.25Over6,500Montananshavealreadycompletedtheassessment.26Low-IncomeWorkersHurtbyRepealThemajorityofpeoplewhowouldlosecoverageunderMedicaidexpansionareemployedbutworkingatlow-wagejobsthatdonotprovidehealthinsurance.27ThoseeligibleforcoveragethroughHELPActincludefoodserviceemployees,cleaningandmaintenanceserviceworkers,officeandadministrativesupport,andconstructionworkers.28Thevastmajorityofthepeoplehurtbyrepealarepeoplelivinginpoverty:50,000Medicaidexpansionrecipientslivebelowthepovertylevel,withtheother10,000livingjustaboveit.29VeteransCouldLoseCoverageVeteransandtheirfamiliesareindangeroflosingtheirhealthcarecoverageifthefederalgovernmentwithdrawsfundingforMedicaidexpansion.PriortotheHELPPlan,Montanahadthehighestrateofuninsuredveterans(17.3%)inthecountry.30RepealingMedicaidexpansioncouldcauseapproximately9,500veteransandfamilymemberstoloseeligibilityforhealthinsurance.31WhilesomeoftheseveteranshaveaccesstoVeteransAffairs(VA)healthcare,manyofthemlivetoofarawayfromaVAhospitalorhealthcareclinictoreceiveadequatecareiftheirMedicaidcoverageistakenaway.RepealingMedicaidExpansionWouldHurtMontana’sEconomyMedicaidexpansionhasincreasedthedemandforhealthcareservicesandsupportedjobsfordoctors,nurses,laboratorytechnicians,andothermedicalservicesstaff.Withmorepeopleemployedinthestate,andwiththenewlyinsuredabletospendmoneyatthegrocerystorethattheypreviouslyspentonhealthcare,thereismoremoneyflowingintotheeconomyandcreatingjobs.PreviousstudiesontheimpactofMedicaidexpansioninMontanashowedthatexpandingcouldcreateasmanyas12,700jobs,ifpermittedtocontinue.32RepealingMedicaidExpansionwouldcauseMontanatolosehundredsofmillionsofdollarseachyearinfederalfunding.In2019,thefirstyearthatrepealofACAwouldtakefulleffect,Montanawouldloseapproximately$698millioninfederalMedicaidfunding.Overthenextdecade,

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Montanawouldloseatotalof$9.8billioninfederalMedicaidfundingtowardhealthreimbursementstoMontanacommunitiesandproviders.33ThelossofMedicaidexpansionfundingcouldhaveadirectimpactonthestate’sgeneralfund.BySeptember2016,justninemonthsaftertheMedicaidexpansionwasimplemented,theHELPActhadalreadysavedthestate$10.6millionbyreducingcostsfortheDepartmentofCorrections($1.3million)andusingfederalfundstopayforcoststhathadbeencoveredbythestate($9.3million).34IfACAweretoberepealed,Montanawouldlosetheopportunityforfuturestatesavings.Infact,astheuninsuredrategrows,thiswouldlikelyputadditionalpressureonthestateandlocalgovernmentsinadditionalcostsofuncompensatedcare.35UncompensatedCareCostsWouldRisewithRepealIfMedicaidexpansionisrepealed,Montanahospitalscouldfacesignificantlosses.In2013,priortotheexpansionofMedicaid,Montana’shospitalsincurred$400millioninuncompensatedcarecosts,overhalfofwhichwasbaddebt.Peoplewithoutinsuranceaccumulatedmostofthesecosts.36WhileafullanalysisontheimpactofMedicaidexpansiontoprovidersmaynotbecompleteuntil2017,initialsurveysofMontana’slargesthospitalsafterthefirstsixmonthsofexpansionhaveshownthesehospitalshaveexperiencedareductioninthenumberofuninsuredpatientsandhaveseenreducedcharitycareandbaddebtexpenses.37Repealingexpansioncouldresultinfinancialtroubleforhospitalsthatwouldseeincreasesintheiruncompensatedcare.MontanaMustActtoProtectCoverageMontanafamiliesandthepublicdeservetoknowhowapotentialrepealwillimpacttheiraccesstoaffordablehealthinsurance.Withlittledetailsandtheuncertaintyofwhatreplacementmaybe,over142,000Montanansarefacedwiththerealriskoflosinghealthcoverage.BeforeCongressvotestorepealtheACA,theremustbeaclearplaninplacethatprotectsallMontanans,includingthoseenrolledinMontana’sHELPplan.Areplacementplanthatprovidesinadequateorlessaffordablecoveragewouldbedevastatingtothepeoplemostinneedofhealthcare.AcknowledgementTheworkuponwhichthisreportisbasedwasfunded,inpart,throughsupportfromtheMontanaHealthcareFoundation.ThestatementsandconclusionsofthisreportarethoseoftheMontanaBudgetandPolicyCenter.

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AppendixTable1:ResidentsinEveryCountyCouldLoseHealthInsurance County HELP Plan Recipients County HELP Plan Recipients Beaverhead 542 Madison 232 Big Horn 1,076 Meagher 192 Blaine 510 Mineral 291 Broadwater 216 Missoula 7,457 Carbon 477 Musselshell 405 Carter 53 Park 1,010 Cascade 5,085 Petroleum 20 Chouteau 243 Phillips 269 Custer 541 Pondera 545 Daniels 43 Powder River 39 Dawson 346 Powell 348 Deer Lodge 582 Prairie 32 Fallon 105 Ravalli 2,860 Fergus 599 Richland 371 Flathead 6,142 Roosevelt 1,040 Gallatin 3,988 Rosebud 564 Garfield 36 Sanders 961 Glacier 1,541 Sheridan 118 Golden Valley 85 Silver Bow 2,625 Granite 121 Stillwater 309 Hill 1,327 Sweet Grass 127 Jefferson 441 Teton 414 Judith Basin 91 Toole 218 Lake 2,397 Treasure 31 Lewis and Clark 3,427 Valley 426 Liberty 186 Wheatland 197 Lincoln 1,619 Wibaux 22 McCone 117 Yellowstone 8,174 1MontanaCommissionerofSecuritiesandInsurance.“HealthCoverageinMontana:2016ReportonHealthCoverageandMontana’sUninsured.”AccessedDecember2016.http://csimt.gov/wp-content/uploads/Enrollment-One-Pager.pdf.2Pear,R.,Steinhauer,J.,andKaplan,T.“G.O.P.PlansImmediateRepealofHealthLaw,ThenaDelay.”NewYorkTimes.December2,2016.http://www.nytimes.com/2016/12/02/us/politics/obamacare-repeal.html?_r=3.3Broaddus,M.andPark,E.“AffordableCareActHasProducedHistoricGainsinHealthCoverage.”CenteronBudgetandPolicyPriorities.December15,2016.http://www.cbpp.org/research/health/affordable-care-act-has-produced-historic-gains-in-health-coverage.4MontanaCommissionerofSecuritiesandInsurance.“HealthCoverageinMontana:2016ReportonHealthCoverageandMontana’sUninsured.”AccessedDecember2016.http://csimt.gov/wp-content/uploads/Enrollment-One-Pager.pdf.

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5Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.6Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.7Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.8CenteronBudgetandPolicyPriorities.“142,000MontanaResidentsWouldLoseCoveragein2019UnderACARepeal.”December2016.http://www.cbpp.org/sites/default/files/atoms/files/12-7-16health-factsheets-mt.pdf.9Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.10TheCommonwealthFund.“MontanaPassesHealthyMontanaKids.”StatesinAction:InnovationsinStateHealthPolicy.January8,2009.http://www.commonwealthfund.org/publications/newsletters/states-in-action/2009/jan/december-2008-january-2009/snapshots--short-takes-on-promising-programs/montana-passes-healthy-montana-kids-plan-act.11MontanaDepartmentofPublicHealthandHumanServices.“EnrollmentDashboard.”September2016.http://dphhs.mt.gov/Portals/85/Statistics/documents/Enrollments-Monthly.pdf.12Mitchell,A.,andBaumrucker,E.,“CHIPandtheACAMaintenanceofEffort(MOE)Requirement:InBrief.”CongressionalResearchService.September19,2016.https://fas.org/sgp/crs/misc/R43909.pdf.13Buettgens,M.,Kenney,G.,andPan,C.“PartialRepealoftheACAthroughReconciliation,CoverageandImplicationsforChildren.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86706/coverage_implications_for_parents_and_children_1.pdf.14Buettgens,M.,Kenney,G.,andPan,C.“PartialRepealoftheACAthroughReconciliation,CoverageandImplicationsforChildren.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86706/coverage_implications_for_parents_and_children_1.pdf.15Buettgens,M.,Kenney,G.,andPan,C.“PartialRepealoftheACAthroughReconciliation,CoverageandImplicationsforChildren.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86706/coverage_implications_for_parents_and_children_1.pdf.16MontanaDepartmentofPublicHealthandHumanServices.“MedicaidExpansionMemberProfile.”November15,2016.http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/Medicaid%20Expansion%20Member%20Profile%20111516_1.pdf.17NationalIndianHealthBoard.“ProtectingtheIndianHealthcareImprovementAct.”Onfilewithauthor.18NationalIndianHealthBoard.“PatientProtectionandAffordableCareAct(AffordableCareAct)SummaryofIndianHealthProvisions.”Onfilewithauthor.19U.S.CensusBureau.“2014AmericanCommunitySurvey1-YearEstimates.”2014.https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_1YR_S2702&prodType=table.20KaiserFamilyFoundation.“HealthandHealthCareforAmericanIndiansandAlaskaNatives(AIANs).”November22,2016.http://kff.org/infographic/health-and-health-care-for-american-indians-and-alaska-natives-aians/.21Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.22Montana64thLegislature.“MontanaHealthandEconomicLivelihoodPartnership(HELP)Act.”2015.http://leg.mt.gov/bills/2015/billpdf/SB0405.pdf.23U.S.DepartmentofHealthandHumanServices.“U.S.FederalPovertyGuidelines.”January1,2016.https://aspe.hhs.gov/poverty-guidelines.24CentersforMedicareandMedicaidServices.“MontanaHealthandEconomicLivelihoodPartnership(HELP)ProgramDemonstration.”ApprovedNovember2,2016.http://dphhs.mt.gov/Portals/85/hrd/documents/1115/ApprovedMTHELPSection1115Waiver.pdf.25OfficeofGovernorSteveBullock.“GovernorBullockAnnouncesNewWorkforceTrainingProgram.”RetrievedDecember2016.https://governor.mt.gov/Newsroom/ArtMID/28487/ArticleID/3103.26MontanaDepartmentofLaborandIndustry.“HELP-LinkWorkforceProgramReport.”November22,2016.http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/DLI_HelpLink_Oversight_Cmte_Report_Nov2016.pdf.27InananalysisconductedbytheMontanaDepartmentofLaborandIndustry,two-thirdsofthoseeligibleforHELPcoverageareemployed.MontanaDepartmentofPublicHealthandHumanServices.“HealthandEconomicLivelihoodPartnershipReport.”

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SubmittedtoLegislativeFinanceCommittee.September29,2016.http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/HELPOversightLCFPresentationSlides9_27_16FINAL.PDF.28DeeMahan.“Top9OccupationsofWorkingbutUninsuredinMontanaWhoWouldBenefitfromExpandingHealthCoverage.”FamiliesUSA.February2015.http://familiesusa.org/product/top-9-occupations-working-uninsured-montana-who-would-benefit-expanding-health-coverage.29MontanaDepartmentofPublicHealthandHumanServices.“MedicaidExpansionMemberProfile.”November15,2016.http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/Medicaid%20Expansion%20Member%20Profile%20111516_1.pdf.30Haley,J.andKenney,G.“UninsuredVeteransandFamilyMembers:WhoAreTheyandWhereDoTheyLive?”UrbanInstitute.May2012.http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf73036.31MontanaBudgetandPolicyCenter.“MedicaidExpansionWouldBenefitMontana’sVeterans.”February2013.http://www.montanabudget.org/wp-content/uploads/2013/08/Medicaid-Expansion-Benefits-Montana-Veterans.pdf.CalculationsbasedonHaley,J.andKenney,G.“UninsuredVeteransandFamilyMembers:WhoAreTheyandWhereDoTheyLive?”UrbanInstitute.May2012.http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf73036.32BureauofBusinessandEconomicResearch.“AnEstimateoftheEconomicRamificationsAttributabletothePotentialMedicaidExpansionontheMontanaEconomy.”TheUniversityofMontana.January2013.33Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.34MontanaDepartmentofPublicHealthandHumanServices.“HealthandEconomicLivelihoodPlanProgressReport.”September29,2016.http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/DPHHS%20HELP%20Act%20Progress%20Report%20LFC9_29_2016.pdf.35Blumberg,L.,Buettgens,M.,andHolahan,J.“ImplicationsofPartialRepealoftheACAthroughReconciliation.”UrbanInstitute.December2016.http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf.36MontanaBudgetandPolicyCenter.“UncompensatedCare:ADragonMontana’sEconomy.”December2014.http://www.montanabudget.org/wp-content/uploads/2014/12/Uncompensated-Care_FINAL.pdf.37MontanaDepartmentofPublicHealthandHumanServices.“HealthandEconomicLivelihoodPlanProgressReport.”September29,2016.http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/DPHHS%20HELP%20Act%20Progress%20Report%20LFC9_29_2016.pdf.