New Montana Medicaid Report Shows Impact of Continuous Enrollment in Medicaid Expansion

In February 2023, the Montana Healthcare Foundation released the third annual Medicaid in Montana report on the state’s Medicaid program and its impact on the state budget, economy and health. This year’s report highlights the role of Montana Medicaid in providing access to critical preventive physical and behavioral health services as the nation emerges from the COVID-19 pandemic, and the sustained role of telehealth in supporting access to health care. The report also found that individuals enrolled in Medicaid expansion had fewer visits to emergency departments each year they were enrolled in Medicaid. At the same time, health care costs shifted from more expensive emergency and inpatient care to outpatient services and pharmacy costs.

The Montana Medicaid program provides nearly 300,000 low-income Montanans (28 percent of the state population)—including adults with low incomes, children, seniors, individuals with disabilities and those who are medically needy—access to physical and behavioral health care services that support their health and well-being. Effective January 1, 2016, the Montana Health and Economic Livelihood Partnership (HELP) Act expanded Medicaid to cover adult Montanans with incomes at or below 133 percent of the federal poverty level (FPL). Montana became the 31st state to expand Medicaid for low-income adults nationwide, and in 2022, approximately 115,000 Montanans were covered by Medicaid expansion.¹

Individuals Enrolled in Medicaid Accessed More Preventive Services in 2021 Compared to 2020

Medicaid coverage enables access to preventive services and screenings, which contribute to earlier diagnoses and treatment for conditions such as breast and colon cancer, hypertension, diabetes, and substance use disorders. In 2020, many Medicaid enrollees delayed preventive care due to COVID-19-related concerns.² In 2021, the number of Medicaid-supported wellness exams in Montana returned to pre-pandemic levels. Condition-specific screenings, including alcohol abuse, breast cancer, cholesterol and diabetes screenings, also increased from 2020 levels.

Telehealth utilization also increased dramatically in the Montana Medicaid program during the COVID-19 pandemic. Telehealth visits peaked in April 2020, representing 53 percent of all mental health services claims and 5 percent of all physical health services claims. By 2021, overall telehealth utilization decreased from peak levels; however, use of telehealth for mental health services has remained higher than the pre-pandemic rate, potentially indicating structural changes in how mental health care is being delivered in Montana. In 2021, approximately 1 in 5 mental health services were delivered via telehealth (Figure 1).

Figure 1. Proportion of Services Conducted by Telehealth (Single-Day Claims, January 2019–December 2021)

For Individuals Enrolled in Medicaid Expansion, Emergency Department Visits Decreased and Health Care Costs Shifted From Emergency and Inpatient Care to Outpatient Services and Pharmacy

The 2023 report also found that Montanans enrolled in Medicaid expansion visited the emergency department less frequently the longer they had coverage. During their first year of enrollment, 17,914 (around 26 percent of) Medicaid expansion enrollees with at least three years of continuous coverage had at least one emergency department visit. During their second year of enrollment, only 15,788 of those enrollees visited the emergency department, a decline of more than 11 percent.

While emergency department use declined, costs for emergency and inpatient care among Medicaid expansion enrollees also decreased. Among Montanans covered for at least three full years between the implementation of Medicaid expansion in January 2016 and March 2020, during their first year of enrollment, on average enrollees had $3,289 in emergency and inpatient costs. By their third year of enrollment, emergency and inpatient costs were $2,692 per enrollee, an 18 percent drop. While emergency and inpatient costs declined, outpatient and pharmacy costs increased, indicating that expansion enrollees may have improved access to the ongoing primary care and medications needed to manage their health conditions, rather than relying on emergency services for intensive care.

Overall, per-enrollee health care costs became more concentrated in outpatient, pharmacy and dental services rather than more intensive emergency and inpatient services over time. During enrollees’ first year of enrollment, on average emergency and inpatient costs comprised 35 percent of health care costs per Medicaid expansion enrollee ($3,289), while outpatient, pharmacy, dental and other costs comprised 65 percent of per-enrollee costs ($6,141). By their third year of enrollment, emergency and inpatient costs dropped to 30 percent of per-enrollee health care costs ($2,692), with outpatient, pharmacy, dental and other costs making up 70 percent ($6,469) (Figure 2).

Conclusion

Additional findings about the impact of the Montana Medicaid program are available in the full 2023 report and data book. Medicaid in Montana: How Medicaid Impacts Montana’s State Budget, Economy and Health was produced by Manatt Health and commissioned by the Montana Healthcare Foundation. The annual, data-driven report could serve as a model for other states and state foundations seeking to develop fact-based reporting about their Medicaid or public health programs, an especially important endeavor as the nation looks past the COVID-19 public health emergency.

^{1. “Status of State Action on the Medicaid Expansion Decision,” Kaiser Family Foundation. February 16, 2023. Available here.}

^{2. “Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns — United States, June 2020,” Centers for Disease Control and Prevention. September 11, 2020. Available here.}